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Referral Form
1-833-8SMILE1
Referral Form
Inspire Dental Downtown Refferral Form – 875 West Hastings, Vancouver, BC, V6C 3N9.
Patients Name
*
Date of Birth*
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Telephone
*
Date Report*
*
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Who to Bill?
Bill Dr.
Bill Patient
3D Cone Beam Computed Tomography (CBCT)
Field of View
Single Site (5cm x 5cm)
Single Jaw
Both Jaws
Tooth Number
Which Jaw
Upper Jaw
Lower Jaw
Reason for Scan
Service Needed
Implant(s) / Graft
Guided Surgery
Orthodontic
Sinus / Airway
Endodontic
TMJ
Post Op
Pathology
Radiology Report Required
Yes
No
Digital Radiography
Special Instructions or Relevant Clinical History
Dr Name
*
Date*
*
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2010
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2008
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2006
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2004
2003
2002
2001
2000
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1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
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1953
1952
1951
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1949
1948
1947
1946
1945
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1943
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1930
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1928
1927
1926
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1923
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1921
1920
Dr Signature
*
Dr Email
*
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