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Imaging Request Form. Patient Surname Forename Male/Female Date of Birth Address Postcode Contact Tel no: Referring Clinician Address Postcode Examination required: Please tick type oppositeOPGcost50Ceph CBCTcost70 180Reason
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How to fill out suffolk orthodontics imaging request

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How to fill out suffolk orthodontics imaging request

01
Start by obtaining the Suffolk Orthodontics Imaging Request form.
02
Fill in the patient's personal information such as name, date of birth, and contact details.
03
Provide the name of the referring dentist or orthodontist.
04
Indicate the reason for the imaging request, whether it is for orthodontic evaluation, treatment planning, or other specific purposes.
05
Specify the type of imaging required, such as X-rays, panoramic radiographs, or cephalometric images.
06
Mention any specific instructions or preferences regarding the imaging procedure, if applicable.
07
Sign and date the form to validate the request.
08
Submit the completed form to the appropriate Suffolk Orthodontics imaging center or facility.

Who needs suffolk orthodontics imaging request?

01
Suffolk Orthodontics Imaging Request is needed by patients who require orthodontic evaluation, treatment planning, or any other imaging related to their orthodontic care.
02
It is also needed by dentists or orthodontists who are referring their patients for imaging services provided by Suffolk Orthodontics.
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Suffolk Orthodontics Imaging Request is a formal document used to request imaging services necessary for orthodontic assessments and treatment planning in the Suffolk area.
The imaging request must be filed by licensed orthodontists or dental professionals who are seeking imaging services for their patients.
To fill out the Suffolk Orthodontics Imaging Request, the applicant must provide patient information, requested imaging type, reason for the request, and sign the form if required.
The purpose of the Suffolk Orthodontics Imaging Request is to obtain the necessary diagnostic imaging that aids in the evaluation and planning of orthodontic treatments.
The information that must be reported includes patient demographics, clinical indications for imaging, type of imaging requested, and any relevant medical or dental history.
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