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CBCT Referrals
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Dentist Name
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Patient Details
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Patient Name:
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Patient History
Radio
Yes
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Relevant Medical History?
If yes, please advise:
CBCT Prescription Details
Please Tick the relevant boxes and provide further details in the space given.
Field of View:
100x85
100x70
50x50
Vertical Position:
Maxilla
Mandible
Occlusal
Tooth Position:
Right
Incisor
Left
Right Molar
Left Molar
Image Option:
Low Dose
Ultra-Low Dose
Voxel Size:
Standard (0.200)
Application (0.300)
Bone Density:
Hard
Normal
Justification for exposure:
OPT prescription details
OPT prescription details
Yes
No
Standard
Front
Left
Right
Justification for exposure:
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