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Send cbct referral form via email, link, or fax. You can also download it, export it or print it out.
How to Use or Fill Out the CBCT Scan Referral Form Online
Ease of Setup
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Ease of Use
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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy for proper identification.
Fill in the patient's phone number, followed by the referring doctor's name and contact details, including address, city, state, zip code, phone, fax, and email.
Select the appropriate CBCT scan options based on your needs. Check all that apply: Guided Surgery (Upper/Lower/Both), Endo, TMJ, or Post-Op. Specify any required field of view dimensions.
For edentulous patients, indicate whether a conventional scanning appliance is available by selecting 'Yes' or 'No'.
Decide if you wish to decline the radiology report by checking the corresponding box. Remember that this means accepting full responsibility for diagnosis.
Finally, sign and enter your license number at the bottom of the form to complete it.
Start filling out your CBCT Scan Referral Form online today for free!
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How to Create a Request Form Define Your Use Case and Requirements. Start Building Your Form. Add and Customize Form Fields. Personalize the Form Design. Set Up Notifications and Approvals. Publish and Share Your Form. Test and Manage Submissions.
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