Online Referral Online Referral Dental X-Ray Request BUNDOORA:18 Scholar DrivePh: 9473 8555 DONCASTER EAST:1020 Doncaster RdPh: 8841 0500 BALWYN North:16 Doncaster Rd Ph: 9473 8555 CAULFIELD Nth:205B Balaclava RdPh: 9523 1025 BENDIGO:86 Baxter StreetPh: (03) 5442 5100 SHEPPARTON:128 Nixon StPh: (03) 5442 5100 Patient Details Name(Required) DOB(Required) Address Contact Phone(Required) Examination Requested Standard X-rays OPG Lat Ceph PA Ceph Bone Age Intra -Orals Cone-Beam CT Scan Maxillary Mandibular Both Arches TMJ Study ENT Other Clinical Information Right Left Right – Top 18 17 16 15 14 13 12 11 Left – Top 21 22 23 24 25 26 27 28 Right – Bottom 48 47 46 45 44 43 42 41 Left – Bottom 31 32 33 34 35 36 37 28 Please select Area of Interest 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 For CBCT Scans: Clinical notes assist with the selection of optimal scan parameters Clinical Notes / Special InstructionsImage / Results Delivery Image / Results Delivery Email CD Cloud Transfer Paper X-ray Film DICOM Data ONLY DICOM data WITH Viewer Referring Doctor * Name(Required) * Provider No(Required) Signature on print version only(Required) * Date(Required) MM slash DD slash YYYY * Required by Health Insurance Act Legislation Additional Information you would like VDIG to know regarding patient or examination:
