CBCT Referral

CBCT referral form

CBCT scans will be taken at our Morningside Practice, 27 Morningside Park, Edinburgh, EH10 5HD

Referrer Information

Patient information

Gender: Female Male

CBCT Output

Please select ONE
CD/USB Email VIEW ONLY SOFTWARE INCLUDED    RAW FORMAT

CBCT areas of interest

MANDIBLE    MAXILLA    BOTH JAWS

Is the patient possibly pregnant?
Yes    No

Indicate specific tooth/teeth (if any):
Right(Upper): 11    12    13    14    15    16    17    18
Right(Lower): 41    42    43    44    45    46    47    48
Left(Upper): 21    22    23    24    25    26    27    28
Left(Lower): 31    32    33    34    35    36    37    38

*OUTPUT CAN BE PROVIDED WITH VIEW-ONLY SOFTWARE OR IN RAW FORMAT COMPATIBLE WITH YOUR OWN PROGRAM

Reason for referral and justification for X-Ray

Implants    Bone Graft    Ortho    Endo    Impacted Teeth    Sinus Exam    TMJ    Oral Pathology


The information that I have given above is correct to the best of my knowledge.

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