Dentist CT Scan Prescription Form
Filled out by Referring Doctor
Patient Name
*
First Name
Last Name
Patient Phone Number
*
Format: (000) 000-0000.
Patient Date of Birth
*
-
Month
-
Day
Year
Gender
*
Male
Female
Non-binary
Other
Dental Office Name
Doctor Name
*
Dentist NPI
Dentist Phone Number
*
Dentist Email
*
example@example.com
Where would you like for us to meet you?
Street Address
Street Address Line 2
City
State
Zip Code
Download Options
*
Secure Cloud Based Access
CD
Format
*
Simplant (With free Viewer)
DICOM (With free PreXion Viewer)
DICOM (For use with any full version software)
Exposure Options
*
Both arches
TMJ - Airway (Including Condyles)
Image with Scan Appliance
Endodontics
Additional Services (check all that apply)
Radiology Report
Surgical Stent
Surgical Guide
Tooth Number(s)
Patient Booking
*
Call Patient
Call Dental Office
Patient will call us
Payment Preference
*
Dental Office will process payment
Patient will process payment directly to DDSSCAN
Charge Dental Office card on file
Doctor Notes & Special Instructions
*
Privacy Policy
Terms and Conditions
Submit
Should be Empty: