Edmonton Diagnostic Imaging Template

Edmonton Diagnostic Imaging - Patient Referral Slip

6643-177th Street, Edmonton AB, T5T 4K3 (P) 780-483-1338 (F) 780-483-1393 info@edxi.com

Patient's Name:

DOB:

Patient Email:

Telephone:

Male: Female: Non Binary

Address:

City:

Prov:

Postal Code:

To be billed to: Patient Referring Dr. Urgent +$50

Patient Insurance Information

Name of policy holder:

DOB:

Insurance Company:

Group#:

Subscriber ID:

Name of policy holder:

DOB:

Insurance Company:

Group#:

Subscriber ID:

Cone Beam Volumetric Scan (to be taken at EDI)

Field of view: Small Medium Large Lower Arch Upper Arch

Print Copies By Mail (Additional Fee) Electronically

Clinical history and concerns:

Pathological Investigation (concern):

Impaction/Supernumerary (concern):

TMJ Closed Open With Myobite

Sinus Investigation Airway

Implant

Maxilla Site(s): (Tooth Number)

Include Ostiomeatal Complex

Soft Tissue Retraction Required

Mandible Site(s): (Tooth Number)

Soft Tissue Retraction Required

Measurements: Yes No

Nerve tracing: Yes No

Surgical Guide

Tooth-borne

Bone-borne

Mucosa Supported

Orthodontic Records

CBCT Traditional Invisalign/Clear Aligner

STL Models

Other

Diagnostic Digital Photographs

Panoramic

Radiology Report

Hand/Wrist

Lateral Cephalometric

PA Cephalometric

Ceph Analysis (Specify type)

Send Your Outside Image(s) for Radiology Reporting Services

CBCT(DICOM & Invivo only accepted)

Plain Film(s)

Dr.s name

Office name

Email Address

Doctor's Signature:
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Name of person submitting referral

Once submitted, this form serves as a valid authentication to provide services as requested.