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Dental Diagnostic Imaging Center | Affordable Radiographs, Digital Imaging and 3D Cone Beam Scanning

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Patient Form

Select Location *

BEVERLY-HILLS

ENCINO

REFERRED BY DOCTOR: *

OFFICE PHONE: *

OFFICE E-MAIL: *

PATIENT NAME: *

BIRTH DATE:

PATIENT PHONE: *

DOCTOR SIGNATURE: *

SEX:

Male

Female

Yes, I am Pregnant

2D DIGITAL IMAGING SURVEYS

Beginning

Progress/Final

Diagnostic Photographs

Panoramic View

Lateral Ceph

PA Ceph

Ceph Tracing

Full mouth series

Periapicals (specify in Notes)

Bitewings

Carpal Index

TYPE OF ANALYSIS:

SPECIFY:

INTRAORAL SCANNING & 3D PRINTING

Open STL/PLY files (digital models)

Invisalign

ClearCorrect

Surgical Guide (specify in Notes)

3D CBCT DIGITAL SURVEYS

Maxilla

Mandible

3rd Molar

TMJ

Implant

Endodontic

Airways

ENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

Dual scan (Marked/unmarked denture provided)

Maxillary sinus floor mapping

Mandibular canal mapping

Slicing

With measurements

Radiology Report (specify in Notes)

TMJ study
Open & closed (MIP or bite index)

NOTES:

DELIVERY

Printed views

CD/Flash Drive

Upload to Cloud (box.com)

DICOM data only

i-CAT TxStudio/Vision viewer

Planmeca Romexis viewer

If you are human, leave this field blank.

Our mission is to provide high quality and affordable radiographs, digital photos and advanced 3D Images. We utilize state of the art technology done in the safest possible way with only two things in mind: excellent patient care and the best image quality.

Our Featured Services

Menu

CBCT Scan
Panoramic X-Ray
Cephalometric X-Ray
Intraoral X-Ray
TMJ Views
Orthodontic Records
Carpal Index
3D Intraoral Scanning
Surgical Guides

Our Locations

Beverly Hills

292 S. La Cienega Blvd. Suite 205
Beverly Hills, CA 00211
424.302.0455

Encino

16661 Ventura Blvd. Suite 508
Encino, CA 91436
818.386.8562

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