Imaging Referral Form

Examination Required: Panoramic X-rayCephalometric X-RayBwings/PA

Purpose/Justification (Mandatory) *

Region of Interest *

Notes (MH/Social Hist) *

IR(ME)R Regulations: To comply, all radiographs must be clinically evaluated to rule out the possibility of coincidental pathology. Moira Wong Orthodontics does not report on dental X-rays, the referrer accepts the responsibility for reporting on the images. We offer a radiography service only.

Date of referral *

Referrers Declaration *
I will discuss the report with my patient and I will make a copy available to the patient on request