Dental CBCT Scan Referral Form Referring Dentist Doctor Name: Practice Name: Email: Phone: Date: RELEVANT XRAYS (PA, BW, PAN) MUST BE INCLUDED FOR ALL PATIENTS, AS PER RCDSO. All metal in the head/neck needs to be removed for the scan. Patient Information Patient Name: Sex: MaleFemaleOthers Date of Birth: Address: Email: Phone: Dental History & Medical Alerts: Indication/s for scan Implant PlanningImpacted TeethTMJ AnalysisPathological LesionEndodontic PurposesOthers, Please Explain: Requested format of the scan Full ReportDICOM Files OnlyBoth Region to be scanned UR PostUR AntLR PostLR AntUL AntUL PostLL AntLL PostRight TMJLeft TMJ Please click or circle the region of interest 1817161514131211212223242526272848474645444342413132333435363738 Additional Comments/Clinical Information/Suspected Diagnosis Please email the completed form to info@robertsonfamilydentistry.ca or Tel: (613) 829-2222 www.robertsonfamilydentistry.ca 2017 Robertson Rd, Ottawa, Ontario, K2H 5Y7
