CBCT Scan RX Order Form

Please complete the entire form below. All fields indicated by * are required. Scans per patient cost $215. 

 
If patient is a minor, please provide the following:
   
If you are an existing customer, you can skip this.
 

We will email the completed radiology report to your email address listed above and the CT scan will be delivered via WeTransfer to the email listed above.






Order Information