Referral Form

Inspire Dental Group

Diagnostic Image Referral Form

Patient's Name:*
Date of Birth:*
Date Report Required:*
Bill Dr.Bill Patient

3D cone Beam Computed Tomography (CBCT)

Field of View

Single Site (5cm x 5cm)Single JawBoth Jaws
Tooth Number(s):
Upper or Lower Jaw: Upper JawLower Jaw
Reason for Scan:
Implant(s) / GraftGuided SurgeryOrthodonticSinus / AirwayEndodonticTMJPost OpPathology

Radiology Report

Radiology Report Not Required

Digital Radiography

Special Instructions / Relevant Clinical History

Dr. Name:*
Dr. Signature:
Dr. Email:*

Inspire Dental Group Downtown

875 West Hastings
Vancouver, BC
V6C 3N9
Phone: 604.670.9700