Patient's Name*Patient's DOB*Patient's Phone Number*Dentist's Name*Dentist's Email* Also Send to Doctor (additional doctor name entered here)Additional Doctor's EmailPlease take scan in: Centric occlusion Teeth apart With implant guide appliance or splint in place (must be provided) Requested field of view: Full Head (TMJ, Surgery, Pathology) Single Jaw (Implants, Pathology, Exo) Single Tooth (Endo) Single Jaw (Implants, Pathology, Exo) Maxilla Mandible Specify Tooth # (Endo)Reason for Referral Implant TMJ Surgery Extraction Pathology Endodontics Other Other ReasonPlease specify any additional instructions belowFee for CBCT Scan The patient will be expected to pay for the service at the time the scan is obtained. The fee for the scan is $250.00 regardless of the size of the field of view or the number of scans taken that day. Multiple scans may be required if the purpose of the CBCT scan is for implant placement. We will provide the patient with a receipt and ask that your office take responsibility for submission to insurance companies should patient reimbursement be desired. Booth Orthodontics will have no involvement in the submission, reimbursement or billing process with the patients insurance company. Radiographic Interpretation The scans we provide are offered as a service, which is not read nor interpreted by Dr. Ryan Booth or Dr. Evan Booth. The scan will be provided to the patient in the DICOM file format with reader software on a USB jump drive. Interpretation of the data contained within the scan file is the sole responsibility of the referring dentist. The patient will have the option to have the scan read by an Oral and Maxillofacial Radiologist for an additional fee or they may waive the right to this service. Booth Orthodontics strongly recommends having the scan interpreted by an Oral and Maxillofacial Radiologist. If the patient requests this additional service, our office will send a copy of the scan to BeamReaders Inc., a group of Oral and Maxillofacial Radiologists, who will read the scan and email a report on their findings to the referring dentist. Follow-up on the results of the scan interpretation will be the sole responsibility of the referring dentist. The fee for this additional service is $150.00 with a standard turn-around time of 7 business days Patient Consent Once the patient schedules with our office they will be electronically sent a consent form that outlines the scope of our services and also details the option to send their scan to Beam Readers. Please encourage patients review this consent form before their appointment in our office.Patient Consent* I have read, understand and agree to the above terms for CBCT services