Cone Beam Scan Referral

Referred by:

Referral Telephone Number:

Patient Name:

Patient Date of Birth:

Month / Day / Year

Patient Phone Number:

Patient Email:

1. Type of Imaging:

Cone Beam CT

Panorex

Ceph (current FG)

CBCT Scan & Report

1 Quadrant

$210 (Plus cost of measurements)

2 Quadrant

$285 (Plus cost of measurements)

4 Quadrant

$335 (Plus cost of measurements)

Implant Measurements Required:

Extra $26.25 per quad

Quad 1

Quad 2

Quad 3

Quad 4

None

Please note if you require two quads, UL/LR or UR/LL is a 4 quad scan.

2. Region Required

Click on a number and write additional comments under "More Information" if needed.

3. Imaging Required For:

Implant Placement:

Pathology

TMJ

Orthodontics

Endodontics

Oral Surgery

Delivery method: Please note we require 2 week turnaround for reports

Additional Referral Notes:

Email Address (Free):

Mail Address ($25):

Please email or fax us a copy of this referral along with giving your patient a copy. Thank you.