Please fill out the information below and click "Submit". A team member will contact your patient as soon as possible. Requesting Doctor Name * Phone * Email * Address Patient Information Name * Phone * Report Options Options * Full field with radiology report ($350) Full field without radiology report ($195) Limited field of view with radiology report ($350) - specify below Limited field of view without radiology report ($195) - specify below Multiple scan sequence with guide ($450) Specific Area Note: Maximum resolution by scan size is designated by color code. Field of View Options 16 x 13 CM 16 x 11 CM 16 x 10 CM 16 x 8 CM 16 x 6 CM Maxillary 16 x 6 CM Mandible 16 x 4 CM 8 x 8 CM Voxel Size/Scan Time Options .4 x 4.8 sec .4 x 8.9 sec .3 x 4.8 sec .3 x 8.9 sec .25 x 14.7 sec .25 x 26.9 sec .2 x 14.7 sec .2 x 26.9 sec .125 x 14.7 sec Comments Please provide any additional details and comments here. Patient Expectations Patient will be expected to pay for service at the time the scan is obtained and a receipt will be provided. The patient and/or the referring office will be solely responsible for submission to insurance companies should patient reimbursement be desired. Scans are provided as a service and are not read nor interpreted by Dr. Paquette. A CD with volume (DICOM image) and native software will be mailed to referring dentist. Interpreting the scan volume is the sole responsibility of the referring doctor. Dr. Paquette strongly recommends having the volume contents read by a qualified Oral and Maxillofacial Radiologist. Interaction with prosthetic laboratory is the sole responsibility of the referring dentist. Should electronic submission to a lab be requested additional fees will apply. Agreement to Terms * I have read, understand and agree to the above terms for CBCT services Doctor Initials * (Dr. Initials) CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.