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
$299 service fee
Do you require digital implant treatment planning? $199 additional fee
The additional cost for this service is $699 for 3-4 days turnaround or $899 for a rushed report delivery