Contrast Oral Radiology

Radiology request

RADIOLOGY REQUEST

Use this form to provide information about your case and upload DICOM files.

Please utilize a secure and private network in a controlled environment for protection of PHI.

Office Name*

Doctor's Name*

Doctor's Phone Number*

Doctor's Email*

Patient name*

Patient birthday*

File Upload*

In a zipped/compressed folder, please drag and drop DICOM files and any other relevant images/files. Contact us if you have questions about exporting or compressing DICOM files.

Type of radiograph*

CBCT - Small field of view (less than one jaw)

CBCT - Medium field of view (mandible, maxilla, or both)

CBCT - Large field of view (12 cm x 12 cm or greater)

CBCT - TMJ assessment with open and closed mouth scans

2D Radiograph - panoramic, BW, PA, lateral cephalometric, etc

MRI - TMJ

Additional services

Additional implant measurements $50 (first two measurements included with report)

Rush case returned within 1 business day $45

Comparison with other CBCT $45

Requested due date

Reports typically take 2-4 business days. Rush reports will be charged accordingly.

Tooth/teeth to evaluate

Purpose of evaluation*

Select the following evaluation requests.

Endodontic evaluation

Implant evaluation

Orthodontic evaluation

Impaction evaluation

Possible pathology

TMJ evaluation

Airway evaluation

Other

If you selected other, please describe your request here

Other pertinent patient information

This may include the patient's medical conditions, surgical history, symptoms, previous biopsy results, etc.

I am a first time client*

Yes

Please complete our business agreement form here to receive your reports.

Business Agreement Link