Online Patient Referral

Patient: *

Patient Phone: *

Patient Date of Birth: *

Bill Scan to: * Patient Doctor

Radiologist to: * Review Rush
* Radiologist return is 3-5 days; Rush is 24 hours

Rush; Bill to: Patient Doctor
* Rush is 4 hour return; regular return is 48 hours

Scan Results Needed By:

Send a Copy (Enter your email):

Image Delivery

  • Online
  • Print
  • CD

Planning Software:

Area of Interest:

Doctor: *

Office Phone: *

Office City: *

Endo

  • Focus Area (5cm, up to 3 teeth) find cracks, lesions, or extra canals

Implant

  • Focus Area (5cm)
  • Both Arches
  • Dual/Denture Scan (for simplant-services)
  • One Arch
  • With Stent

Extract

  • Focus Area (5cm)
  • Two Focus Areas, 2 Wisdome
  • Both Arches, Four Wisdom
  • One Tooth

Ortho

  • 3D Survey Arches with Condyles

TMJ

  • Wide Open
  • At Rest
  • Closed
  • Appliance

Other

  • Sinus
  • Airway
  • Oral Pathology (describe below)
  • Spine
  • Fracture

2D Only

  • Panoramic
  • Ceph Tracing
  • Ceph

Patient Scanned In:

San Francisco 490 Post Street, Suite 301
Mountain View 100 W. El Comino, Suite 63B
Mill Valley 163 Miller Ave, Suite 4
Oakland 4217B Piedmont Ave

Reasons for Scan:

Ask the Radiologist: When review is ordered, radiologist will map nerve, measure implant area, comment on anatomy and answer questions

You can fill out our Referral Slip and FAQ in about 30 seconds and submit it online, or print it out and have the patient bring in the form at the time of the conebeam scan appointment.