Referral for CBCT Imaging | Saskatoon Oral Radiology

Saskatoon Oral Radiology Referral Form

December.06.2024

"*" indicates required fields

Patient's name*

First Last

Date of Birth*

Sex*

Male

Female

SK Health Card #*

Primary Phone Number*

Secondary Phone Number

Mailing Address*

Street Address City State / Province / Region ZIP / Postal Code

Referring Doctor's Name*

Referring Doctor's Phone Number*

Referring Doctor's Email*

CBCT for*

Please specify

Please Indicate Specific Site(s) and/or Anatomical Region(s) of Interest:*

Clinical Information / Medical History*

Please upload images or other documents to accompany this referral and ensure that the date(s) when the images were taken is/are on the image name or provided in clinical information above:

Drop files here or

Max. file size: 64 MB.