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 (open STL file) iCAST-ABO base digital models Hard models Specify: 3D CBCT DIGITAL SURVEYS ImplantOrthodonticEndodontic TMJ 3rd Molar Other 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 DVD given to PatientHard copies mailed to Dental Office (2-3 days)Upload to Cloud (box.com) DIOCM, Romexis viewerDICOM, TxStudio/Invivo viewerDICOM only
