Submit a Referral

3-D CBCT Imaging Referral Form

By signing below, I request Northgate Dental Imaging to acquire and share CBCT images, according to my specifications. I understand my images are provided in a universal DICOM format for use with other proprietary software. I have obtained authorization from my patient for these procedures. I understand that Northgate Dental Imaging are not liable for any interpretation or manipulation of imaging data.

Clear Signature

After you receive a referal from your doctor you can CLICK HERE to make an appointment.