Referral for Cone-Beam CT Imaging

Patient Name: 
Patient Date of Birth:
Patient MUSoD axiUm ID (if applicable):
Patient Telephone:
Referring Doctor:
Referring Doctor's e-mail address
Doctor's Address:
Doctor's Telephone:
Doctor's FAX:
Region to be scanned:
Primary reasons for scan:
   Implants       Imaging stent provided
   TMJ       Closed Mouth       Open Mouth       With Splint
   Mandibular canal/3rd molar apex relationship
   Impacted Teeth
   Jaw Pathology
   Jaw Surgery
   Orthodontic Procedure
   Pt. in occlusion
   Mand & Max separated
Has the patient had bone grafting?
If yes to the above, what region?
Any specific information desired? Any other information that will help in the CT scanning procedure?
Image data output:
   Prints of region of interest
   CD with DICOM file for import into other software
        (Simplant, NobelBiocare, Dolphin, etc.)

  Send directly to Materialise/Simplant
   Other image output
If other image output, please specify:

Patients should report to Faculty Practice (Lower Level, Room 004)
15 minutes before appointment to register.