Referral Form

Patient Information

Patient Name (required)

Appointment date & time

Referring Doctor's Email (required)

D.O.B. (required)

Telephone (required)

Approx. fee

Please specify which office to send this form:

Toronto OfficeBarrie Office

Cone Beam Computer Tomography

TMJ (please check all that apply):closeopenbite registration

Airway Analysis

3D images

Implants

(please check areas of interest):
87654321 1: | 2: 12345678
87654321 4: | 3: 12345678

patient will bring stent

Image output

Measurements:
Vertical measurements made from a minimum of crestal width.

Hard copy printsDICOM filesViewing softwareSimplant file

Email images to

Conventional Imaging

PanoramicLateral cephalometricCephalometric analysisPosterior-anterior cephalometriclateral cervical spinewith bite

Digital Photography

extraoralintraoral3D facial photographic scan

Instructions and patient history

Referred by Doctor (required)
Date

For your records, a copy of this form will also be sent to the email provided above.