Clinician Details (Mandatory) *

Name of referring doctor / dentist

First Name

Last Name

Phone

(###)

###

####

ACC Related

Yes

No

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Reporting of the CBCT scan – please select one *

Referring dentist/medical practitioner will do the report personally

Referring dentist/medical practitioner will arrange the reporting

PerioCare to arrange the referral to a medical radiologist for reporting

Size of the Scan *

Upper arch

Lower arch

Full Mouth

Quadrant 1

Quadrant 2

Quadrant 3

Quadrant 4

Volume of the Scan *

11cm x 10cm

8 cm x 8 cm

5cm x 5.5cm

Resolution of the Scan *

Standard Definition (SD)

High Definition (HD)

Method of Data Transfer *

USB Stick

Export to the cloud

File Type *

Wrap and go with viewer

Dicom for third party

Dicom exam export

Radiology Report (Teledent in Australia)

Please note, the CBCT scan fee is NZD $297.00 including GST. The fee for the medical radiology report is approximately AUD $190.00.

Yes

No