Get Referral Form.pdf - Orthodent 3d Imaging

Filling out the Referral Form for OrthoDent 3D Imaging online is a straightforward process. This guide will provide you with detailed instructions to ensure all relevant information is accurately captured for efficient processing.

Follow the steps to complete the Referral Form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter the patient’s name in the designated field, followed by their date of birth and phone number.
3. Fill in the date of referral and the name of the person who is referring the patient.
4. Include the scheduled appointment date and time in the appropriate section.
5. Indicate the estimated cost for the imaging services in the corresponding field.
6. Mark the appropriate services required, including the type of imaging studies, such as 3D CBCT scans or specific implant/restorative studies, by placing a checkmark next to the relevant options.
7. If necessary, specify details for each type of study requested, such as sites for implants or types of orthodontic studies.
8. Add any additional comments in the comments section, providing situational context or specific requirements.
9. Ensure to fill out the referring doctor’s signature and Texas dental license number, confirming the medical necessity of the procedure.
10. After completing the form, save your changes, and choose to download, print, or share the form as required.

Complete your form online to ensure a smooth referral process.