Patient Referral Form

FAX PRIOR TO APPOINTMENT: 706.262.2985PLEASE BRING THIS REFERRAL FORM WITH YOU ON THE DAY OF YOUR APPOINTMENT.
Patient Name:Date Of Birth:Phone:

Address:City:State: Zip:

Parent's Name (if minor):Appointment:

*CT Scan will include a Radiologist Report unless box is checked below.
NO Report Requested

Maxillofacial CBCT ROI:

Mandibular Arch:Maxillary Arch:Both Arches:

Patient is being referred to aid in treatment of:

Implant(s) Site #:Full Mouth ReconstructionSinus/Pathology

TMJ ExamImpactionEndodonticsOrthodontics

**Reason for Scan (ICD-9):

ICD-9 Codes:
473.9 Unspecified chronic sinusitis525.19 Other loss of teeth
520.1 Supernumerary teeth525.20 Atrophy Edentulous Alveolar
520.6 Disturbances in tooth eruption (impaction)525.20 Unspecified atrophy of edentulous alveolar ridge
521.10 Excessive attrition(approximal and occlusal wear)525.21 Minimal atrophy of mandible
521.12 Excessive attrition, extending into dentin525.22 Moderate atrophy of mandible
521.13 Excessive attrition, extending into pulp525.23 Severe atrophy of mandible
521.14 Excessive attrition, localized525.24 Minimal atrophy of maxilla
521.15 Excessive attrition, generalized525.25 Moderate atrophy of maxilla
522.8 Radicular cyst (apical, periapical)525.26 Severe atrophy of maxilla
523.31 Aggressive periodontitis, localized; perio abscess525.41 Complete edentulism, class
523.32 Aggressive periodontitis, generalized525.51 Partial edentulism, class
524.62 Arthralgia of temporomandibular joint526.4 Inflammatory conditions (i.e. Abscess, Osteomyelitis)
524.64 TMJ sounds on opening and/or closing526.0 Developmental odontogenic cysts
525.11 Loss of teeth due to trauma782.0 Disturbance of skin sensation (numbness)
525.12 Loss of teeth due to periodontal disease

Comments:

Left Side Center Right Side

Other Services:
Orthodontic Records (digital photographs, CD with volume views of skull and dentition, panoramic radiograph, lateral cephalogram)
Orthognathic Pre and Post Surgery Records (digital photos,volume views, panoramic, lateral cephalogram, PA and cs)
3d DICOM Files to Party Software (Simplant™, NobelGuide™)


Images returned to referring doctor in the following format: CD-nnt (with viewing software) and DICOM files
By signing below, I request 3D Imaging CSRA and its associates to acquire, review, upload the images to oral maxillofacial radiologist and have obtained authorization from the patient for these procedures.
Dr.(Print Name): Signature: Date:
PAYMENT IS DUE WHEN SERVICES ARE RENDERED. WE DO NOT ACCEPT ASSIGNMENT OF INSURANCE.
UPON REQUEST FORMS WILL BE PROVIDED FOR POSSIBLE REIMBURSEMENT FROM YOUR INSURANCE CARRIER. CONTACT YOUR CARRIER FOR COVERAGE INFORMATION.
$: FEE DUE AT TIME OF SERVICE

 
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