DOB DATE MM/DD/YR MM/DD/YR Client Name Referring Dentist Name Client Phone Number Referring Dentist Phone Number Client Address Referring Dentist Address (including email) Cost of scan: $200.00 per view (hard copy $15.00) PLEASE CHOOSE OPTION Mail me a CD with the DICOM files formatted for (Includes: CT scan of area + guide, guide only and radiographic report) Nobelguide software on it. Radiographic guide sent with patient Email me the download links to the formatted DICOM data. Make measurements as well (This is a much faster option. The DICOM files are usually Expedite CBCT 1-2 Days $100 3-6 Days $75 delivered in 24 hours or less). 7-12 Days $50 12-17 Days $25 A radiographic report by an oral radiologist is included with all scans. No manual measurements are automatically provided unless they Choose area of Dentoalveolar CT scan of 8cm or less: are requested on the form 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 Client Diagnosis (please send most recent x-rays of area of concern): Fax to Kincardine Dentistry Choose one of the following patient contact options: Fax this form to us and we will contact the client to set Call with client information up an appointment. Please provide us with the patient’s next appointment (if applicable). Call us with the client’s information and set up an 519-395-5109 appointment when they are present in your office. 519-395-5100 Kincardine Dentistry 6 Millennium Way Kincardine, ON N2Z 0B5 519-395-5100 (P) 519-395-5109 (F)
DOB MM/DD/YR Client Name Client Phone Number Client Address Cost of scan: $200.00 per view (hard copy $15.00) (Includes: CT scan of area + guide, guide only and radiographic report) Radiographic guide sent with patient Make measurements as well Expedite CBCT 1-2 Days $100 3-6 Days $75 7-12 Days $50 12-17 Days $25 Choose area of Dentoalveolar CT scan of 8cm or less: 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 Client Diagnosis (please send most recent x-rays of area of concern): Choose one of the following patient contact options: Call with client information Call us with the client’s information and set up an appointment when they are present in your office. 519-395-5100 Kincardine Dentistry 6 Millennium Way Kincardine, ON N2Z 0B5 519-395-5100 (P) 519-395-5109 (F) DATE MM/DD/YR Referring Dentist Name Referring Dentist Phone Number Referring Dentist Address (including email) PLEASE CHOOSE OPTION Mail me a CD with the DICOM files formatted for Nobelguide software on it. Email me the download links to the formatted DICOM data. (This is a much faster option. The DICOM files are usually delivered in 24 hours or less). A radiographic report by an oral radiologist is included with all scans. No manual measurements are automatically provided unless they are requested on the form Fax to Kincardine Dentistry Fax this form to us and we will contact the client to set up an appointment. Please provide us with the patient’s next appointment (if applicable). 519-395-5109
CTreferral-forms.docx