Patient Information
Referring Doctor Information
Treatment Plan

Is your patient coming with a radiological template ? Yes No

If yes then Pt. was trained to place template     Dr. will be on scanning site


Maxilla
Mandible
Both Arches
Choose Arch


Indicate teeth or
area of interest
     
     
Software
Preferred Reproduction Format
CD Prints Via Internet Radiological Report All of the above
Processing
Patient





Mask Mandible



Special Requests: