Patient Referral Form

CBCT Patient Referral Form
Please enter referring dentist or physician's name
CBCT data set will be send to this email address through a HIPPA compliant system
Please enter patient's phone number
Do you require digital implant treatment planning? Additional fee may apply.
Are you requesting a 3D printed implant guide? Phone consultation with referring Dr is required to discuss specific requirements of the treatment plan, implant system, etc, prior to the design and 3D printing of the guide. Additional fee may apply.