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Close Appointment form

Dental CT Request

Online Dental CT Request

Please complete the following form and we will contact the patient to make an appointment.





Referrer Name (required)

Practice Address (required)

Referrer Email (required)

Referrer Telephone (required)

Patient Forename (required)

Patient Surname (required)

Patient D.O.B. (required)

Patient Address (required)

Patient Telephone (required)

Area to be scanned (required):

Is the patient coming with a radiographic stent?
 Yes No

Is the patient possibly pregnant?
 Yes No

Justification for X-Rays (required):
 Implants Bone graft Impacted teeth Endodontics Sinus exam TMJ Oral pathology Ortho

Clinical indications (required):

Please select your preferred CBCT format:
 iCat Vision DICOM Simplant Planner Simplant One Shot Simplant View

Payment
 Referrer Patient

CD Delivery

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