TMJ Questionnaire Form

Referral for Diagnostic Imaging

Patient:

D.O.B.:

Appt. date & time:

Telephone:

Parent’s Name (if minor):

Approx. fee:

CONE BEAM COMPUTER TOMOGRAPHY

TMJ (please check all that apply)

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Airway Analysis (3D Images)

Area of Interest
Reason

8
7
6
5
4
3
2
1
1

2
1
2
3
4
5
6
7
8

8
7
6
5
4
3
2
1
4

3
1
2
3
4
5
6
7
8

patient will bring stent

Image output:

Measurements (vertical measurements made from a minimum of mm crestal width)

DICOM files

Viewing software

Simplant file

Email images to:

CONVENTIONAL IMAGING

Panoramic
Lateral cephalometric
Cephalometric analysis

Lateral cervical spine
Posterior-anterior cephalometric
Other

Instructions and patient history

Referred by Doctor

Date

1867 Yonge Street, Suite 602
Toronto, Ontario M4S 1Y5
T 416.440.3892 F 416.440.3931

Einfo@hmfr.ca

4 Checkley Street, Suite 300
Barrie, Ontario L4N 1W1
T 705.735.4442 F 705.735.4404