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

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HOME / Patient Form

Patient Form

Select Location *

BEVERLY-HILLS

ENCINO

APPOINTMENT DATE:

APPOINTMENT TIME:

:

REFERRED BY DOCTOR: *

OFFICE PHONE: *

OFFICE E-MAIL: *

OFFICE E-MAIL: *

PATIENT NAME: *

BIRTH DATE:

GUARDIAN:

PATIENT E-MAIL: *

PATIENT PHONE:

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 and Bitewings)

Periapicals

Bitewings

Carpal Index

TYPE OF ANALYSIS:

SPECIFY:

INTRAORAL SCANNING & 3D PRINTING

iRECORD (open STL file)

Invisalign

ClearCorrect

Hard models

Articulated

Surgical Guide

3D CBCT DIGITAL SURVEYS

Maxilla

Mandible

3rd Molar

TMJ

Implant

Orthodontic

Endodontic

Airways

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

Radiographic stent or marked denture provided

Maxillary sinus floor mapping

Mandibular canal mapping

Slicing

With measurements

Radiology Report

NOTES:

DELIVERY

DVD given to Patient

Upload to Cloud (box.com)

Hard copies mailed to Dental Office

DICOM, Romexis viewer

DICOM, TxStudio/Invivo viewer

DICOM only

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

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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