Radiologist Report Referral
Please verify that you are human
*
Referring Doctor / Upload File(s)
Referring Doctor
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
CBCT Scan Upload
*
Single Site
Full Head
Single Arch
2D Image
Both Arches / TMJ
Was Patient scanned at Orbit Imaging?
*
Yes
No
For DICOM files please export your patient's scan as uncompressed multiple files DICOM, and zip folder before uploading
Browse Files
Drag and drop files here
Choose a file
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Report Details
Radiology Report Type Requested
CBCT - 1 scan (all FOVs) - $189
CBCT - 2 scans (same time point) - $209
CBCT - 2 scans (compare different time points)- $276
2D Pano / Ceph - $149
Rush Radiology Report - $50
Yes
No
Add Implant Site Measurements ?
Yes
No
Select Implant Site Quadrant(s) & Tooth Number(s)
Upper Left
Upper Right
Lower Left
Lower Right
Choose Image Portfolio Type
Sinuses / Upper Airway / TMJ
Implant Single Jaw
Implant Dual Jaw
Pathology
Ectopic Eruptions / Impactions
Upper Right
17
16
15
14
13
12
11
Upper Left
27
26
25
24
23
22
21
Lower Left
37
36
35
34
33
32
31
Lower Right
47
46
45
44
43
42
41
Trace IAN Canal(s)? - $39
Yes
No
Indicate preferred implant manufacturer and product type below
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Sex
*
Please Select
Male
Female
Other
Reasons for Requesting Report
*
Relevant Medical History & Treatment History. Notes
*
Fee Estimate / Submit
Fee Estimate (CAD$)
Promo Code
Final Fee Estimate
Date Signed
*
-
Month
-
Day
Year
Date
Doctor's Signature
*
Order Report
Order Report
Should be Empty: