Referral for Cone-Beam CT Imaging

Patient Information




Doctor Information




Region Information



Primary Reasons for Scan








Be sure to specify position of the mandible below.











Be sure to specify position of the mandible below.





Mandible Position

Other Information


All CBCT scans will be read by Dr. Lisa Koenig, a Board-certified OMFR. The CBCT files and report for outside referrals will be uploaded into a HIPAA-compliant data-transfer site for retrieval by the referring doctor. New referring doctors will receive a username and password to the site. Files will be saved as InVivo files and an InVivo viewer will be provided.



Reports for patients of MUSoD will be uploaded under attachments in the patient's axiUm chart. The CBCT files can be accessed through various viewing sites throughout the school.



Submission of this form will automatically refer your patient for scheduling. Patients within the MUSoD system will be scheduled through radiology. For outside referrals, someone from Faculty Practice will contact the patient to schedule.

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