Online Referral Form

    Please use this form to refer your patients to our office for imaging services.

    Doctor and Patient information

    Confirmation message will be sent to this email after the form is completed.

    Please indicate office location for multiple offices.

    Address of Patient

    Scan information

    Processing time

    Cases will be processed within 10 business days (excluding civic and statutory holidays), if this case is a rush, please select one of the options below

    Report Preference

    Type of Report*

    Cases will be processed within 10 business days (excluding civic and statutory holidays), if this case is a rush, please select one of the options below

    Mandibular wisdom tooth investigation site of interest*

    Implant site to be measured

    Quadrant 1 Tooth Numbers*

    Quadrant 2 Tooth Numbers*

    Quadrant 3 Tooth Numbers*

    Quadrant 4 Tooth Numbers*

    Please select the appropriate services:*

    Image Format*

    You will receive an email copy of the report to the doctor's email address. Do you need a printed copy as well?