Referral for Radiology | Dr. Paul J. Tiernan DDS

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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. #:

Δ

Diplomate of the American Board of Oral and Maxillofacial Surgery | Fellow of the American Association of Oral and Maxillofacial Surgery

707-546-4727 | 30 Doctors Park Drive, Santa Rosa, CA

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