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Referring Provider

Patient Information

Name
Referred By Doctor
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Type of Radiographs

Type of Radiographs enclosed (*if emailed, PLEASE encrypt):
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Radiograph Visual (Baby/Primary)
Radiograph Visual (Adult)

Evaluate for Treatment As Noted

Extractions
Orthognathic Surgery
Dental Implants
Reconstructive Surgery
Bone Grafting
Facial Cosmetic Surgery
Exposure of Teeth
BOTOX® / Dermal Fillers
Apicoectomy
Facial Trauma
Infection
TMD
Pathology
3D CT

Case Notes

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