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Bulleen : 9850 4818 Bundoora: 9473 8555 Caulfield North: 9523 1025

BULLEEN:	195 Thompsons Road	Ph: 9850 4818	E: [email protected]
BUNDOORA:	18 Scholar Drive	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

Clinical Information

Standard X-rays

Examine Dentition

3rd Molars

Caries Status

Perio Status

Cone Beam CT

Implant Study

Impaction / Localisation

IDC localisation

Airway

Additional Clinical Notes & Special Instructions

Image Presentation

Referring Provider Details

* Name:

*Provider No:

*Signature on Printout:

* Date:

* Required by Health Insurance Act Legislation

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