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

PATIENT INFORMATION

REFERRING DOCTOR INFORMATION

SCHEDULING INFORMATION

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Location *

(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? *
Implant area *

SERVICES

Radiology Report (Additional Charge of $85) *
Indicate teeth or area of interest *
Do you have any implant planning software? *
Preferred Format *
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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 *
Authorization / Acknowledgement
Doctor's Signature *
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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. 1257 NW 7th Street. Boca Raton, FL. 33486
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