(415) 837-5990

Refer A Patient Today

Please fill out the referral form below and we will contact the patient to schedule an appointment.

You can also download a copy of our referral form here and submit it to info@revealdiagnostics.com

DOB (Patient Date of Birth)
Next appointment Date
Bill Doctor for Scan (Patient charged unless Bill Doctor is checked)

3D CBCT IMAGING

Field of view

One Arch
Both Arches
Lower Skull (24x19cm)
Limited Field of View (Focus, 3 consecutive teeth)

INDICATION

IMPLANT
Scan w/ appliance provided by doctor
Scan in occlusion (default 5mm separation)
ENDO
IMPACTION
TMJ
Open
Closed
Wearing Appliance
PATHOLOGY
SLEEP APNEA/AIRWAY
ORTHOGNATHIC
SINUS
CHIROPRACTIC- UPPER CERVICAL

GUIDED SURGERY

Dual scan - Marked denture or radiographic guide
Reveal to design guide and send proposal to doctor (full arch scan required)
Provide DICOMS for doctor to plan guided surgery without Reveal

* Please provide stone model OR request optical impression below

INTRAORAL IMPRESSION

Invisalign
Invisalign Refinement
Invisalign and iRecord


Vivera Retainer
Surgical Guide Impression
“STL” File for Laboratory Use

2D IMAGING

Pano
Ceph


Ceph Tracing
Photography


CBCT FMX

DELIVERY

Online
DICOMS only



Print
Jpeg


CD
Rush (4 hour + $50)
Rush (1 hour + $150)
Radiologist Review (4 day return)
Rush (Radiologist 1 day with rush + $30)

ORTHODONTIC

3D Ortho Bundle (CBCT scan, ceph, pano, TMJ, airway, photos)
2D Ortho Bundle (Ceph, ceph tracing, pano and photos)
2D Limited Ortho Bundle (ceph, pano, photos)

Send digital copy to another doctor



Please fill out the referral form below and we will contact the patient to schedule an appointment.

You can also download a copy of our referral form here and submit it to info@revealdiagnostics.com

DOB (Patient Date of Birth)
Next appointment Date
Bill Doctor for Scan (Patient charged unless Bill Doctor is checked)

3D CBCT IMAGING

Field of view

One Arch
Both Arches
Lower Skull (24x19cm)
Limited Field of View (Focus, 3 consecutive teeth)

INDICATION

IMPLANT
Scan w/ appliance provided by doctor
Scan in occlusion (default 5mm separation)
ENDO
IMPACTION
TMJ
Open
Closed
Wearing Appliance
PATHOLOGY
SLEEP APNEA/AIRWAY
ORTHOGNATHIC
SINUS
CHIROPRACTIC- UPPER CERVICAL

GUIDED SURGERY

Dual scan - Marked denture or radiographic guide
Reveal to design guide and send proposal to doctor (full arch scan required)
Provide DICOMS for doctor to plan guided surgery without Reveal

* Please provide stone model OR request optical impression below

INTRAORAL IMPRESSION

Invisalign
Invisalign Refinement
Invisalign and iRecord
Vivera Retainer
Surgical Guide Impression
“STL” File for Laboratory Use

2D IMAGING

Pano
Ceph
Ceph Tracing
Photography
CBCT FMX

DELIVERY

Online
DICOMS only


Print
Jpeg
CD
Rush (4 hour + $50)
Rush (1 hour + $150)
Radiologist Review (4 day return)
Rush (Radiologist 1 day with rush + $30)

ORTHODONTIC

3D Ortho Bundle (CBCT scan, ceph, pano, TMJ, airway, photos)
2D Ortho Bundle (Ceph, ceph tracing, pano and photos)
2D Limited Ortho Bundle (ceph, pano, photos)

Send digital copy to another doctor



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