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CBCT Scan Referral Form 2026
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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.
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Related links
CBCT/3-D Imaging referral form. If you have questions, contact the Oral Diagnosis Radiology department at 617-358-8300, option #2.Read more
by LM Dobbyn 2013 Cited by 32 Information was obtained from CBCT request forms, case notes and radiology reports. third of scans were carried out within 4 weeks of referral.