Dental CBCT Intake Form
Please complete this form to provide your information for the dental cone beam CT procedure.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Referring Dentist Name
*
Purpose of Exam / Area to be Imaged
*
Please Select
Implant Planning
Endodontic Assessment
Orthodontic Evaluation
TMJ Evaluation
Pathology Assessment
Other
Relevant Medical Conditions (select all that apply)
None
Diabetes
Heart Disease
Bleeding Disorders
Other
Are you currently taking any medications?
*
No
Yes (please list below)
Do you have any allergies?
*
No
Yes (please specify below)
Is there any chance you may be pregnant?
*
No
Yes
Not applicable
Have you had previous dental or facial imaging (X-rays, CBCT, CT, MRI)?
No
Yes (please specify below)
Submit Intake
Should be Empty: