One Kneeland Street, Boston MA 02111 2026

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Referring Dentist Information' section. Enter your name, department, telephone number, fax number, and mailing address including street, city, state, and zip code.
Next, move to the 'Patient Information' section. Input the patient's name, date of birth, Axium number (if applicable), home address details (street, city, state, zip code), and telephone numbers for home, work, and cell.
In the 'CBCT Requested' section, select the appropriate options based on the type of scan required. Check all that apply such as 'Only For Implants', 'Full Head Scan with TMJ', or any specific site/area needed.
Provide any clinical information or diagnosis relevant for the Maxillofacial Radiologist in the designated area.
Review all entered information for accuracy before saving or sending your completed form via fax or email as indicated at the bottom of the document.

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