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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.