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Patient First Name
Patient Last Name
Date of Birth
Month —Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day —Please choose an option—12345678910111213141516171819202122232425262728293031
Year —Please choose an option—20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
Street Address
City
Province
Postal Code
Patient Phone Number
Patient's email
Prescribing Dentist : Dr.
Prescribing Dentist Email/Phone
Reason for referral (To be filled by the Doctor)
Teeth/Area Requested:
Upload a 2D image:
Lesion/Pathology
Implant(s)
Impacted Tooth/Teeth
Sinus
Inferior Alveolar Nerve Localization
Implant Measurement Required
Hard Copy Required
Other Reason for CBCT:
Additional Information
Sextant/Quadrant (Small FOV 5x5)$250.00
with Implant(s)$275.00
Full Arch (Medium FOV 8x5)$300.00
with Implant(s)$325.00
Full Mouth (Large FOV 8x8)$375.00
with Implant(s)$400.00
Digital scan with Trios/Medit scanner: $85.00 (STL file will be emailed to you for surgical guide fabrication)
Dr. Signature
Date
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