Cone Beam Scan Referral | Paquette Orthodontics Charlotte's leading provider of Invisalign. Damon braces & Invisalign for children & adults in Charlotte & Mooresville, North Carolina

Requesting Doctor Name: *

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I am requesting the following CBCT scan be obtained for:

Patient's Name: *

Patient's Phone: *

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.

I have read, understand and agree to the above terms for CBCT services

(Dr. Initials)

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