Refer For CBCT

CBCT Referral Form

    Dentist Details

    Please write your full name above including your GDC Number. This will act as an electronic signature.

    Patient Details

    CBCT Referral Details

    Select Type of Scan

    Small Field 3DSingle JawDual Jaw

    Justification For Scan

    ImplantsSinus LiftEndodontics3rd MolarPerioOther

    Click here to download/print a referral form

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