Get the free CBCT Request Form

Division of Oral and Maxillofacial RadiologyCONEBEAM COMPUTED TOMOGRAPHY (CBC) REQUEST FORM FOR EXTERNAL REFERRING PRACTITIONERSPATIENT INFORMATION Name:Date of Birth:Gender:Mailing Address: Phone

How to fill out cbct request form

How to fill out cbct request form

1. Fill out the patient's personal information such as name, date of birth, and contact details.
2. Specify the reason for requesting a CBCT scan and indicate the area of interest.
3. Provide any relevant medical history or existing conditions that may impact the scan results.
4. Include any specific instructions or preferences for the scan procedure.
5. Sign and date the form to confirm accuracy and consent.

Who needs cbct request form?

1. Dentists
2. Orthodontists
3. Oral and maxillofacial surgeons
4. Endodontists
5. Prosthodontists
6. Periodontists
7. Any other healthcare professionals requiring detailed 3D imagery of the dental and facial structures

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What is cbct request form?

The CBCT request form is a document used to request cone-beam computed tomography imaging.

Who is required to file cbct request form?

Dentists and healthcare providers who need CBCT imaging for their patients are required to file the CBCT request form.

How to fill out cbct request form?

To fill out the CBCT request form, providers must enter patient information, reason for CBCT imaging, and any relevant medical history.

What is the purpose of cbct request form?

The purpose of the CBCT request form is to ensure proper documentation and justification for the use of CBCT imaging.

What information must be reported on cbct request form?

The CBCT request form must include patient demographics, reason for imaging, referring provider information, and any relevant medical history.