CBCT Dentist Referral - Rankin & Fiume Orthodontics

Patient Name:First and Last

Patient DOB:mm/dd/yyyy

Patient's Phone Number

Dentist's Name:First and Last

Dentist's Email:valid email address

Also send to Doctor:First and Last

Additional Doctor's Email:valid email address

Please send the scan by:

Give scan to patient Burn to disk, Send by mail Burn to USB drive, Send by mail

Is viewing software required?

Yes No

Please take scan in:

Centric occlusion Teeth apart With implant guide appliance or splint in
place (must be provided) Implant guide appliance or splint by itself
(must be provided)

Requested field of view:

Full Head (TMJ, Surgery, Pathology) Low Normal
Single Jaw (Implants, Pathology, Exo) Maxilla Low Normal HD
Mandible Low Normal HD
Single Tooth (Endo) Low Normal HD
Specify Tooth #:

Reason for Referral:

Implant TMJ Surgery Extraction Pathology Endodontics Other

Please specify any additional instructions:

Fee for CBCT Scan

The patient will be expected to pay for the service at the time the scan is obtained. The fee for the scan is $200.00 regardless of the size of the field of view or the number of scans taken that day. Multiple scans may be required if the purpose of the CBCT scan is for implant placement. We will provide the patient with a receipt and ask that your office take responsibility for submission to insurance companies should patient reimbursement be desired.

Radiographic Interpretation

The scans we provide are offered as a service, which is not read nor interpreted by Dr. Rankin or Dr. Fiume. The scan will be sent to your office in the DICOM file format. Interpretation of the data contained within the scan file is the sole responsibility of the referring dentist. The patient will have the option to have the scan read by an Oral and Maxillofacial Radiologist for an additional fee or they may waive the right to this service. Dr. Rankin and Dr. Fiume strongly recommend having the scan interpreted by an Oral and Maxillofacial Radiologist. If the patient requests this additional service, our office will send a copy of the scan to BeamReaders Inc., a group of Oral and Maxillofacial Radiologists, who will read the scan and email a report on their findings to the referring dentist. Follow-up on the results of the scan interpretation will be the sole responsibility of the referring dentist. The fee for this additional service is $150.00 with a standard turn-around time of 3-5 business days.

The patient requests to have the CBCT scan read by an Oral and Maxillofacial Radiologist and understands that they are responsible for additional costs. The patient will be responsible for the total fee of $350.00 to include the CBCT scan with the radiology report. The oral radiology report will be emailed to the general dentist.

No, the patient understands the risks and benefits of having their CBCT scan read and interpreted by an Oral and Maxillofacial Radiologist; however, they knowingly decline the referral. The patient will be responsible for the total fee of $200.00 to include the CBCT scan without the radiology report.

General CBCT Information and Patient Consent Forms

Links for general CBCT information for patients and our CBCT patient consent form can be found in Patient Forms under the New Patient tab located at the top of our menu bar on our homepage. Please encourage patients to access this information and review it before their appointment in our office.

I have read, understand and agree to the above terms for CBCT services.

Dr. Initials: