Patient - Schedule Appointment
(Patients: Please UPLOAD or BRING referral form)
Referring Dentist Name
Referring Dentist email
example@example.com
Services
Patient’s Name
*
Patient's Email - for reminder
example@example.com
Patient's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Estimated Cost
Appointment
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Invoice
Patient
Doctor
Unique ID
Copilot UUID
CBCT Services: Includes Free Viewing Software and DICOM
Cone Beam CT Scan
Cone Beam CT Scan with Cross Sections
TMJ: Ooen/Close Cone Beam CT Scan
Airway Study: CBCT Scan, Airway Radiology Report, and sleep appliance digital impressions Additional Views
Additional Views / Area of interest
Additional CBCT and Digital Services:
Print-Outs: Physical Cross sectional print-outs
Radiology Report Interpretation
Virtual Implant Planning: Implant Concierge
Digital Impressions: surgical guide/night guard/Appliance
3D Facial Scan: For Ortho and Restorative Design (Coming Sept 2025)
Area of interest
Implant Brand
Arch
Maxilla
Mandible
Both
Orthodontic Package & Services:
Ortho Records: Includes Pano, Ceph, Tracing, Photos and Digital Study Models Tracing:
Panoramic
Invisalign Records: Includes, Pano, Photos, and Digital Impressions
Composite 8 Photos
Cephalometric
Ceph Tracing
Invisalign Digital Impressions
Carpal (Wrist)
Digital Ortho Study Models (Digital impressions and both arch 3D model prints)
Cephalometric
Lateral
A-P
Cephalometric Tracing Type
Arch
Maxilla
Mandible
Both
Notes Relevant History / Area of Interest
Should be Empty: