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.