CBCT Referral

Please complete either the printed or electronic CBCT referral form below.

Electronic CBCT Form

Scottish Orthodontics CBCT Referral Form

CBCT REFERRAL FORM

Referrer Information

Patient Information

Gender:

CBCT Output

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CBCT AREAS OF INTEREST

IS THE PATIENT POSSIBLY PREGNANT?:
Indicate specific tooth/teeth (if any):
*OUTPUT CAN BE PROVIDED WITH VIEW-ONLY SOFTWARE OR IN RAW FORMAT COMPATIBLE WITH YOUR OWN PROGRAM

Justification for X-Ray

The information that I have given above is correct to the best of my knowledge.



Security Measure