CBCT Scan Referral Form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy for proper identification.
3. 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.
4. 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.
5. For edentulous patients, indicate whether a conventional scanning appliance is available by selecting 'Yes' or 'No'.
6. Decide if you wish to decline the radiology report by checking the corresponding box. Remember that this means accepting full responsibility for diagnosis.
7. Finally, sign and enter your license number at the bottom of the form to complete it.

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