CBCT scans CBCT scans REFERRER DETAILS AND DELIVERY ADDRESSName of Referrer:(Required) Practice name: Address: Telephone: Email: PATIENT DETAILSAppointment 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 ONLYPatient 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 £140Maxilla £140Both Jaws £240Quadrant / sectional £120OPG £75.00
