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Dr. Tiernan
Staff
Services
Regular Extractions
Wisdom Teeth
Dental Implants
Pathology
Bone and Tissue Grafts
Gnathos Radiology
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General Anesthesia
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Implant Post-Operation
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Patient Information
Referral for Radiology
Contact
Referral for Radiology
Brian W. Payne DDS
(707) 546-5234
36 Doctors Park Dr.
Santa Rosa, CA 95405
Paul J. Tiernan DDS
(707) 546-4727
30 Doctors Park Dr.
Santa Rosa, CA 95405
Patient's Name
First
Last
Patient's Date of Birth
MM
DD
YYYY
Today's Date
Date Format: MM slash DD slash YYYY
Appointment Date
Date Format: MM slash DD slash YYYY
Referred By:
Gnathos
Procedure
Panorex
Lateral Ceph (Closed)
Lateral Ceph (Rest)
PA Ceph
Anterior PA Radiographs (Series)
PA Radiograph (Individual)
Hand/Wrist Radiograph
Panorex TMJ
Occlusal Radiograph
Cone Beam CT
Cone Beam CT (Limited FOV)
Cone Beam CT (2nd Limited FOV)
CBCT Report
CBCT Report- Implant
CBCT Report- TMJ
CBCT Report- Pathology
CBCT Report- Dental Impactation
CBCT Report- Airway
Tooth Number (If PA Radiograph is checked)
Special Instructions
Kaiser #:
Auth. #:
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