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Call
1-800-881-4432
Home
For Doctors
For Patients
Contact
Make a Payment
Doctor Login
Refer a Patient
Submit the patient and clinical information needed for a doctor-directed CBCT scan. After the referral is received, the patient or practice can proceed with a separate scan request.
"
*
" indicates required fields
Name
This field is for validation purposes and should be left unchanged.
Patient Information
Name
D.O.B.
Address
Phone
Referring Doctor Information
First Name
Last Name
Address
Phone
Doctor's Email
Enter Email
Confirm Email
Confirmation
Email me a copy of this form to the above email address
Email me a copy of this form to a custom email address
Custom Email
*
Enter Email
Confirm Email
Scan Information
Treatment Plan
Implants
Dental Impaction
Airway Assessment
Ortho
Sinus Exam
TMJ Exam
Endodontics
Oral Pathology
Other
Please describe:
Is patient coming with radiological template?
Yes
No
If yes, then
Patient was trained to place template
Doctor will be on training site
Scan area
Maxilla
Mandible
Indicates teeth of interest for measurement purposes
Teeth of interest (Maxilla)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Teeth of interest (mandible)
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
Payment Responsibility
Payment Responsibility
*
Doctor
Patient
Post Scan Processing
Package
*
Standard: CBCT Scan of one or both arches ($345)
Premium: CBCT Scan + Radiological Report + PDF with Measurements Via Portal ($445)
Complete: CBCT Scan + Radiological Report + PDF with Measurements Via Portal + Prints + CD ($485)
Software
Dicom/Blue Sky Free Viewer (Free)
SimPlant Planner: .SIM or .SPR file type (+$15 per arch)
Invivo Viewer: .INV file type (+$15 Inv ortho, pano, tmj)
SimPlant Viewer: .SMA file type (+$15 per arch)
Preferred Reproduction Format
Via Internet (included in price)
PDF Without Measurements Via Portal (+$3 one arch, $5 for both)
PDF with Measurements Via Portal (+$5 one arch, $8 for both)
Ortho (+$10)
Pano (+$10)
TMJ (+$45)
CD (+$20)
Prints (+$40)
Radiological Report (+$125)
Airway Assessment Radiological Report (+$145)
Dual Scan Procedure
Maxilla (+$140)
Mandible (+$140)
Masking
Maxilla (+$80)
Mandible (+$80)
Virtual Implant Placemnet
Yes (+$155 for the first implant. +$40 for each implant after)
Rush Processing (within 2 hours)
Yes (+$25)
Implant System Name
Implant Name
Lab Name
Special requests
