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 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
Both
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
Mandible Site(s): (Tooth Number)
Measurements:
Yes
No
Nerve tracing:
Yes
No
STL Models for Surgical guide
Orthodontic Records Package
STL Models, Diagnostic Photographs, Lateral ceph, Panoramic (n/c)
Ceph Analysis
(Specify type)
CBCT or
2D Ceph/Pan (select your choice)
Invisalign/Clear Aligner purposes
Individual Services
Lateral Cephalometric
PA Cephalometric
Diagnostic Digital Photographs
Panoramic
Hand/Wrist
STL Models
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:
Sign with mouse
Name of person submitting referral
Once submitted, this form serves as a valid authentication to provide services as requested.
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