Dental CBCT Scan Request Form

Filled out by Referring Doctor

Patient First Name*

Patient Last Name*

Patient Phone*

Patient Date of Birth*

Gender*

Male Female Other

Clinic Name

Dentist Full Name*

Dentist NPI

Dentist Phone*

Dentist Email*

Where are you located?

Select Download*

Secure Cloud Based Access CD

Exposure Options*

Both arches TMJ – Airway (Including Condyles) Image with Scan Appliance Endodontics

Additional Services (check all that apply)

Radiology Report Surgical Guide

Doctor’s Notes and Instructions

Thank You!

Your CT scan prescription form has been successfully submitted.

Our team will review it and get back to you shortly.