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 INTRAORAL SCANNING& 3D PRINTING iRECORD (open STL file) Invisalign ClearCorrect iCAST-ABO base digital models Hard models Articulated Surgical Guide 3D CBCT DIGITAL SURVEYS Maxilla Mandible 3rd Molar TMJ Implant Orthodontic Endodontic Other Dual scan Radiographic stent or marked denture provided Maxillary sinus floor mapping Mandibular canal mapping SlicingWith measurments RADIOLOGY REPORT NOTES: DELIVERY DVD given to PatientUpload to Cloud (box.com)Hard copies mailed to Dental Office DICOM, Romexis viewerDICOM, TxStudio/Invivo viewerDICOM only
