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 your Patient?
Street Address
Street Address Line 2
City
State
Zip Code
Download Options
*
Secure Cloud Based Access (Box.com)
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
Panoramic 2D Scan
Additional Services (check all that apply)
Radiology Report
Surgical Stent
Surgical Guide
Radiology Report Notes (If needed)
Tooth Number(s)
Patient Booking
*
Call Patient
Call Dental Office
Patient will call us
Patient already scheduled
If Patient is Already Scheduled:
DATE AND TIME OF APPOINTMENT
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: