8 ‫جاف‬

7 6 ‫صالح‬
5 4 3‫حمە‬
2 ‫خالد‬
1 1 ‫دکتۆر‬
2 3 4 5 6 7 8
8 ‫ڕوو‬
7 ‫شەویلگەو‬
6 5 4‫ددان و‬
3 ‫و‬2 ‫دەم‬1‫تیشکی‬
1 ‫پسپۆڕی‬
2 3 4 5 6 7 8
B.D.S – M.SC (Oral & Maxillofacial Radiology)

Pt. Name :………………………...………. Birthdate :……………........

Type of Image
Peri apical OPG PA cephalon
Lat.cephalo TMJ View CBCT (3D)

Reason of referral
Diagnosis Implant Endo Orthodontic
Pathology Trauma Impaction Other
Please select which one you need
CD File Report Film or Paper
Any details: ……………………………………………………………………..…………………

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