DENTAL MEDICAL IMAGING
PRACTITIONER DETAILS
NAME OF PRACTITIONER
First Name
Last Name
PRACTICE NAME
First Name
Last Name
PRACTICE ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PRACTICE PHONE NUMBER
-
Area Code
Phone Number
PRACTICE EMAIL
example@example.com
PATIENT DETAILS
APPOINTMENT DATE
APPOINTMENT TIME
FORENAME & SURNAME
First Name
Last Name
DOB
PHONE NUMBER
-
Area Code
Phone Number
PAYMENT
Doctor
Patient
CBCT SCANNER
AREA OF INTEREST CBCT ONLY
Mandible
Maxilla
Both Jaws
IS THE PATIENT COMING WITH A RADIOGRAPHIC STENT?
Yes
No
IS THE PATIENT POSSIBLY PREGNANT?
Yes
No
EXTRAS
2D IMAGING
Digital Panoramic (OPG)
Digital Cephalometric
No Extra Needed
Ceph Tracing Report
3D IMAGING
Full CBCT Scan
No Extra Needed
Extra
Extra Copy
Pathology Report
Radiology Report
No Extra Needed
PLEASE SELECT YOUR PREFERRED CBCT FORMAT:
DISCOM Files
STL
No Extra Needed
CLINICAL INDICATIONS
DIGITAL SIGNATURE (ACCEPTANCE OF T&C'S)
*
I accept the T&C
By using this form you agree with the storage and handling of your data by this website..
Patient's Signature
*
Submit
Should be Empty: