DigiScan Rx Form

Thank you for choosing DigiScan of FL. To request an appointment with one of our technicians, please fill in the information below.

PATIENT INFORMATION

First Name *

Last Name *

Birth Date (MM/DD/YYYY) *

Home Phone *

Cell Phone

Address *

City *

State *

Zip *

REFERRING DOCTOR INFORMATION

Doctor Name *

Office # *

Address *

City *

State *

Zip *

Fax #

Office Email *

Doctors Email (So we may contact you if we have any questions or need clarification on RX form)

Doctors Cell # (So we may contact you if we have any questions or need clarification on RX form)

SCHEDULING INFORMATION

Appointment Date Request * +

Location *

Doctor's Office

Patient Home or Office

(We will contact you within 24 hours to try and accommodate the chosen date selected above)

IMPLANTS

Is your patient coming with a radiographic template? *

Yes

No

Implant area *

Maxilla

Mandible

Both

SERVICES

Radiology Report (Additional Charge of $85) *

Yes

No

Indicate teeth or area of interest *

Do you have any implant planning software? *

Yes

No

If yes, specify

Preferred Format *

CD- ROM

Dropbox - Email

Special Instructions

0/255 characters

Guided implant surgery system

If other, please specify

Comments

PAYMENT INFORMATION

Total Charges for Above Checked Services: $375.00

All payments for CBCT Scans will be due in full when services are rendered. If the Reffering Doctor is responsible for payment. Please provide payment confirmation prior to the appointment, otherwise the Patient will be responsible for payment. If a Radiology report has been selected the total charge will be $460.00.

Responsible Party for Payment *

Patient

Doctor

Authorization / Acknowledgement

Doctor's Signature *

clear

Date (MM/DD/YYYY) *

DISCLAIMER: The above referring Doctor acknowledges and agrees that interpretation of the CBCT Scan, including but not limited to the Data reformatting, diagnostics, and treatment planning are for the purpose of assisting the Referring Doctor/ Clinician and or radiologist in diagnosis and pre-surgical planning, decisions and interpretations are solely the responsibility of the referring Doctor. The referring Doctor understands and agrees that DigiScan of Florida, LLC is not responsible for providing any interpretation of the CT images, and therefore waives, releases and discharges DigiScan of Florida, LLC from any and all claims relating to the diagnosis and treatment and any pathology findings of patient.

DigiScan of Florida,LLC. Boca Raton, FL. 33433

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Implant planning	Sinus assessment	Inferior alveolar nerve	Third molar assessment	Endodontic surgery	Oral pathology assessment
Airway/sinus assessment	Sleep apnea study	TMJ assessment