3dmobilescanform rw .pdf

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Original filename: 3dmobilescanform-rw.pdf
Title: ReferralForm2
Author: Rene Folsom

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P A T I E N T

I N F O R M A T I O N

Patient Name: ______________________________________________ Date of Birth: _________________________
Address: ______________________________ City: ___________________ State: _______ Zip: ___________
Home Phone: _________________ Cell Phone: _________________ Email: ______________________________

R E F E R R I N G

D O C T O R

I N F O R M A T I O N

Doctor’s Name: ___________________________________________________________________________________
Address: ______________________________ City: ___________________ State: _______ Zip: ___________
Office: _______________________ Fax: _______________________ Back Line: ___________________________

S C H E D U L I N G

I N F O R M A T I O N

Appointment Date: _____________ Appointment Time: ___________ Location: ____________________________
Address: ______________________________ City: ___________________ State: _______ Zip: ___________
All appointments will be confirmed one day prior to appointment. Payment is due when services are rendered by cash or check.

REASON(S) FOR CONE BEAM CT REFERRAL
(CHECK ALL THAT APPLY):
Pre-surgical planning:
Implant planning
Sinus assessment
Inferior alveolar nerve
tracing/assessment
Mental nerve tracing/assessment
Third molar assessment
Anatomy or tooth morphology
assessment
Periodontal surgery
Endodontic surgery

PLEASE MARK AREAS
OF INTEREST:

Other:
Oral pathology assessment
Airway/sinus assessment
Sleep apnea study
TMJ assessment
Open
Closed
Both
with bite registration
with splint
Guided implant surgery system used:
NobelGuide
Simplant
Implant Logic
IDent
Keystone
Other ________________________

POST-SCANNING INSTRUCTIONS (CHECK ALL THAT APPLY):
Send DICOM file
Send Report
Mail DICOM file and/or Report (on a CD)
Send DICOM file and/or Report (email/ftp)
Please send printed report

Orthodontic survey requested
Use new preferences
Use preferences on file
Please send additional referral slips

* The below signed understands the reformatted images provided by 3D Mobile Scan are for assisting the referring clinician and/or radiologist in the diagnosis and
pre-surgical planning. 3D Mobile Scan is not licensed to diagnose or interpret the images produced from any scan. Every scan includes a Cone Beam CT
interpretation report from an oral and maxillofacial radiologist.

Signature of referring doctor (required): ________________________________
Special Instructions:

Email: ________________________

CT INTERPRETATION
ORAL AND MAXILLOFACIAL RADIOLOGY
UNIVERSITY OF
FLORIDA,
FLORIDA 32610-0414
Reports
By GAINESVILLE,
BeamReaders.com

P A T I E N T

I N F O R M A T I O N

Patient Name: ____________________________________________________________________________________
Date of Birth: ______________________________________________ Sex: ________________________________

D O C T O R

I N F O R M A T I O N

Doctor’s Name: ___________________________________________________________________________________
Specialty: _________________________________________________ Email: _______________________________
Address: ______________________________ City: ___________________ State: _______ Zip: ____________
Office: ______________________ Fax: ______________________ Back Line: ____________________________

E X A M

I N F O R M A T I O N

Today’s Date: ___________________________________

Exam Date: _____________________________________

TO BE COMPLETED BY PHYSICIAN DENTIST
(please print legibly)

Pertinent History:

Signs, Symptoms, Relevant Diagnosis:

Specific Question(s) to be answered by this study:

Signature of doctor (required): ____________________________________

Date: ____________________________

PLEASE FAX COMPLETED FORMS TO (386) 427-9905

Submit by Email

Print Form

Save To Computer


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