CBCT scans

CBCT scans

REFERRER DETAILS AND DELIVERY ADDRESS

Name of Referrer:(Required)

Practice name:

Address:

Telephone:

Email:

PATIENT DETAILS

Appointment Date:

MM slash DD slash YYYY

Name(Required)

First Last

Male

Female

Date of Birth:(Required)

MM slash DD slash YYYY

Phone

2D IMAGING

Digital Panoramic (OPG)

Digital Lateral Ceph

Digital PA Ceph

Ceph Tracing Report

2D OUTPUT

FTP & Email

PACS Cloud Viewer

Photo Paper

CD

EXTRAS

Express Processing

UK Radiology Report

Full Radiology Report

Extra copy

AREA OF INTEREST CBCT ONLY

Patient coming with a radiographic template

Denture Marked

Separate Template

Is the patient pregnant?

Yes

No

Both Jaws

Maxilla

Mandible

Sectional/Quadrant

Upper Right

18

17

16

15

14

13

12

11

Upper Left

21

22

23

24

25

26

27

28

Lower Right

48

47

46

45

44

43

42

41

Lower Left

31

32

33

34

35

36

37

38

(If no teeth are selected the whole jaw will be scanned)

CBCT FORMAT

i-CAT Vision

Xelis Planner

PACS Cloud Viewer

SimPlant Planner

SimPlant View

SimPlant OneShot

MGUIDE

DICOM Files

iDent

NobelGuide

Romexis Viewer (CD only) (Mac & Windows)

JUSTIFICATION FOR X-RAY

Implants

Bone Grafting

Impacted Teeth

Endodontics

Airway Assessment

Sinus Exam

TMJ

Oral Pathology

Ortho

Perio

CLINICAL INDICATIONS (mandatory)

CBCT OUTPUT

Cloud & Emai

Photo Paper

CD

PAYMENT

Doctor

Patient

Signature(Required)

I agree.

Fees

• Mandible £140
• Maxilla £140
• Both Jaws £240
• Quadrant / sectional £120
• OPG £75.00