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Dental X-Ray Request BUNDOORA: 18 Scholar Drive Ph: 9473 8555 E: [email protected] BULLEEN: 195 Thompsons Road Ph: 9473 8555 E: [email protected] CAULFIELD Nth: 148A Hawthorn Rd Ph: 9523 1025 E: [email protected] BENDIGO: 86 Baxter Street Ph: 5442 5100 E: [email protected] DENTAL X-RAY REQUEST Patient Details *Name: *DOB: Address: * Contact Phone: Examination Requested Standard X-rays OPG Lat Ceph PA Ceph TMJs Bone Age Intra-Oral/s Cone-Beam CT Scan Maxillary Mandibular Both Arches TMJ Study ENT Other Others: Clinical Information Right 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Please select Area of Interest Left Standard X-rays Examine Dentition 3rd Molars Bone Pathology Perio Status Cone Beam CT Implant Study Impaction IDC localisation TMD Airway Study Clinical Notes / Special Instructions Image / Results Delivery Email CD Cloud Transfer Paper X-ray Film DICOM Data ONLY DICOM data WITH Viewer Referring Doctor * Name: *Provider No: *Signature on Printout: * Date: * Required by Health Insurance Act Legislation
