Patient Referrals

Patient referrals
Phone: 212-227-0243
Email: 3ddental@outlook.com
Address: 23 Warren St., Suite 10
New York, NY 10007
PATIENT:
First Name: Last Name:
Phone: Email:
DOCTOR:
First Name: Last Name:
Phone: Email:
Address:
Street City
State Zip Code
CASE TYPE:
 Implant  Impaction  Supernumerary
 Pathology  Sinus  TMJ Study
 Ortho  Other
IMAGE MODELING SOFTWARE:
 Noble  Ez3D Plus  SimPlant
REQUEST APPOINTMENT TIMES (Mon – Fri, 10 AM – 6 PM):
SCAN TYPE:
 3D  Pano
WILL PATIENT HAVE RADIOGRAPHIC GUIDE?
 Yes  No
REGION OF INTEREST (Select One):
 Dual Arch Scan  Single Arch Scan (select teeth)  Quadrant Scan (select teeth)
Maxilla:
1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16 
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Mandible:
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
32  31  30  29  28  27  26  25  24  23  22  21  20  19  18  17 
Additional Notes: