Fresno Dental Scan
3D Dental Services and Cone Beam Dental Scans in Fresno, CA
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Patient Referral Form
CBCT Patient Referral Form
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Referring Doctor's Name
Please enter referring dentist or physician's name
Referring Doctor's Email Address
CBCT data set will be send to this email address through a HIPPA compliant system
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Patient's phone number
Please enter patient's phone number
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CBCT scan required
Maxillary arch
Mandibular arch
Dual arch
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Digital Implant treatment planning?
Yes
No
Do you require digital implant treatment planning? Additional fee may apply.
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3D Printed Surgical Guide?
Yes
No
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.
Interested in CBCT technology and dental implants? Submit your info in this form
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Name
First
Last
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Email
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Phone number
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