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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