Follow the steps to complete the referral form online successfully.

1. Press the ‘Get Form’ button to access the CBCT Scan Referral Form and open it for editing.
2. Enter the patient’s name in the designated field, ensuring the spelling is correct.
3. Provide the patient’s date of birth in the format of month/day/year.
4. Fill in the patient’s phone number for easy contact.
5. In the section for the referring doctor, input your name along with the clinic or practice information.
6. Complete the address section with the relevant details such as street address, city, state, and zip code.
7. Add the doctor's phone number and fax number to facilitate communication.
8. Include the doctor’s email address for electronic correspondence.
9. Select the appropriate CBCT scan options by marking the relevant choices for guided surgery, endodontics, TMJ, or post-operative needs.
10. If applicable, indicate if the case is edentulous or nearly edentulous and whether a Conventional Scanning Appliance is needed.
11. If the case involves implants or endodontics, check the tooth location for accuracy.
12. Decide if you wish to decline the radiology report by selecting the specified option.
13. Provide your signature and license number to authenticate the form.
14. Once all sections are completed, save the changes to the document, then proceed to download, print, or share the form as needed.

Complete and submit your Dental Crafters Network CBCT Scan Referral Form online for efficient processing.