Download Patient Information: Additional CBCT and Digital Services

7800 N Mopac EXPY, Suite 115
Austin, TX 78759
Office 512/795-9950
Fax 512/795-9951
www.imagdent.com
Patient Information:
Patient: Please bring this prescription with you!
Doctor: Please keep a copy for your records.
Appointment Date:
Referring Dentist:
Patient Name:
Invoice:
Patient
Doctor
Estimated Cost:$
Patient Phone #:
Patient DOB:
Delivery Options:
Web Delivery
Mail CD/Paper
Rush ($25)
Please provide ICD 10 Code(s) to help maximize
reimbursement:
Secondary
Primary
CBCT Services: Includes Free Viewing Software and DICOM
Cone Beam CT Scan
TMJ Open/Closed Cone Beam CT Scan
Additional View:
Teeth
Additional CBCT and Digital Services:
Print-Outs: Cross sectional print-outs (Please mark teeth on tooth chart!)
Radiologist Interpretation: (Provide notes to radiologist in notes section)
Virtual Implant Planning: (Please mark teeth on tooth chart!)
Default Software: Implant Concierge
Implant Brand
Digital Impressions for Surgical Guide
Other
Maxilla
Mandible
Both
Orthodontic Packages & Services:
Ortho Records: Includes Pano, Ceph,
Tracing, Photos, and Digital Study Models
Tracing:
Panoramic
A-P
Invisalign Records: Includes
Pano, Photos, and Digital Impressions
Ceph Tracing:
Invisalign Digital Impressions
Carpal (Wrist)
Digital Ortho Study Models
Cephalometric:
Lateral
Interpretation
Yes
No
Maxilla
Mandible
Both
Notes: Required for Radiology Interpretation
License #
Doctor’s Signature:
Date:
/
/
iMagDent provides technical services only at the request of a licensed practitioner. iMagDent does not provide interpretive or therapeutic
services. Your doctor may request an interpretation by a dental r diologist. All images and results are sent directly to your doctor.