UCSF CBCT RxV1 by WqO2CZ6

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									       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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