MUSOD - CBCT Referrals

Marquette University School of Dentistry CBCT referral form.

This form is for outside referrals and patients of Faculty Practice only. Submission of the form will automatically refer your patient for scheduling. A representative from our radiology department will contact the patient to schedule an appointment.

CBCT files and reports will be uploaded into a HIPPA-compliant data transfer site for retrieval by the referring doctor. New referring doctors will receive a username and password for the site. Files will be saved as an InVivo file and an InVivo viewer will be provided. DICOM files will also be provided upon request.

Patient Name

Patient Date of Birth

Patient Date of Birth<div></div>
	Month	Day	Year



Please Select:	Month - Please Select:	Day - Please Select:	Year - Please Select:

Patient MUSoD AxiUm ID (if applicable - Optional)

Patient Telephone

Patient Email

Referring Doctor Name

Referring Doctor's email address

Please indicate your practice location

Practice or Clinic
Marquette University Clinic