Cbct request form 2026

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This document is a referral form for Cone-Beam Computed Tomography (CBCT) services at Maxillofacial Diagnostic Imaging in Boston, MA. It includes sections for the referring dentist's information, patient details, and specific CBCT requests related to dental procedures. The form also outlines fees for different types of scans and provides contact information for appointments and inquiries.

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Click ‘Get Form’ to open the cbct request form 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. Provide the patient's name, date of birth, Axium number, home address (street, city, state, zip code), and telephone numbers for home, work, and cell.
In the CBCT Requested section, select the appropriate options for the scan type by checking the relevant boxes. Specify if it’s for implants or other purposes as listed.
Finally, include any clinical information or diagnosis that may be relevant for the Maxillofacial Radiologist in the designated area.

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