beverly-hills 292 S. La Cienega Blvd. Suite 205 Beverly Hills, CA 90211 Phone: 424.302.0455 Encino 16661 Ventura Blvd. Suite 508 Encino, CA 91436Phone: 818.386.8562 Desirable Appointment Date: Desirable Appointment Time: Referred By Doctor: Office Phone: Office E-mail: Patient Name: Birth Date: Guardian: Patient Cell Phone: Patient E-mail: Pregnant 2D DIGITAL IMAGING SURVEYS Beginning Progress Final Diagnostic Photographs Panoramic View Lateral Ceph PA Ceph Ceph Tracing Type of analysis: Full mouth series (Periapicals and Bitewings) PeriapicalsCarpal Index Specify: Bitewings 3D INTRAORAL SCANNING& 3D PRINTING iRECORD iCAST-ABO base digital models Invisalign Other: Hard modelsArticulated Surgical Guide Specify: 3D CBCT DIGITAL SURVEYS ImplantOrthodonticEndodontic TMJ3rd MolarOther Maxilla Mandible Both arches Dual scan Radiographic stent or marked denture provided Maxillary sinus floor mapping Mandibular canal mapping SlicingWith measurments CBCT RADIOLOGIST REPORT Specify: DELIVERY Hard copy printsCD/DVDUpload to Cloud (box.com) DICOM datai-CAT Tx Studio/Invivo (Beverly Hills Only)STL-file Same dayNext day2-5 business days (mail)
