UCSF 3-D CRANIOFACIAL IMAGING CENTER DIVISION OF ORTHODONTICS 707 Parnassus Avenue Box 0438, D1118 San Francisco, CA 94143-0438 APPOINTMENTS : (415) 476-2841 FAX : (415) 514-0377 (Referring doctors: please fax copy of this request form prior to patient appointment). (Patient: Please check in with the Orthodontics receptionist on the 3 rd floor). Patient Name UCSF Chart # Patient Phone # Patient # (A) Asian (B) African-American (C) Caucasian (D) Hispanic (E) Other ( __________________________ ) Referring Dr.___________________________________ Phone # Address Specialty Please note the area(s) of concern Impacted teeth # Supernumerary teeth # Proposed implants # Cleft palate areas – describe Asymmetries – describe Proposed orthognathic surgery – describe Sinus lesions – describe TMJ status – describe Possible lesions – describe Other conditions or comments: The cost of scan is $350 which includes: One 3-D scan session, processed images printed on photo quality paper, a CD of archived images/video clips, and a basic dental radiologist report. A detailed pathology- specific radiologist report is an additional $35.
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