Refer a Patient

Refer a Patient

Get greater certainty for you and your patients by referring them for a Clarity 3D scan at The Orthodontic Centre. Here’s how it works:

You complete and submit the Imaging Request Form (below)
We send your patient an automated email with preliminary information about our location and what they can expect.
We call your patient to make an appointment. Depending on the location of the patient there may be virtually no waiting time.
Your patient attends The Orthodontic Centre where the image is taken and checked. Then they’re free to go. We will make the patient aware that full payment for the image is expected on the day.
We then forward the images to you on a convenient CD which you can view from any computer. No special software is required and the CD will automatically run.

Clarity 3D Imaging Request Form

Patient Details

Patient Name *

D.O.B (Date of Birth)

Address *

Suburb/Town *

Patient Email *

Home phone *

Mobile

Practitioner Details

Referring Practitioner *

Practice *

Contact Number *

Contact Email *

Reason for investigation

Pre-Surgical
Implant placement
Impacted third molar surgery
Other dentoalveolar surgery

Suspected

Impacted teeth
Root resorption
Supernumary teeth
Cysts
TMJ pathology
Other pathology (please explain to assist imaging)

Description of area to be imaged

To select areas for Imaging, tick the boxes below.

Right					Left
Upper:	TMJ	Molar	Premolar	Canine	Incisor	Canine	Premolar	Molar	TMJ
Lower:	Ramus	Molar	Premolar	Canine	Incisor	Canine	Premolar	Molar	Ramus

Notes:

The file and viewing software will be mailed to you on a CD, and saved on our server.

Regrettably no imaging can take place unless all steps are completed.