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Endodontic Associates

Endodontic Associates CBCT SCAN / Panoramic Request

Option 1: Print Request

or
 

Option 2: Submit Request Electronically

* Referring Doctor
* Patient Name
* Appointment (Date & Time):
Please list tooth/teeth or area for treatment:
Comments: 


CBCT Only:
Please perform a CBCT scan of tooth/teeth or area (50 mm x 37 mm): (Available on CD only.)

Panoramic Only:
Please perform digital panoramic radiograph:

Send by:
CD
Printed
Office email on file
Other


 


 
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