First *


Middle


Last *


Original Date of Scan *


Original Procedure *


Referring Doctor *


Referring Doctor Address *


Referring Doctor Phone *


Your Email Address *


What are you requesting? (Please be specific with your request – Do you want a copy of the original request or did you need for us to look at a different tooth or area which is different from the original scan. Do you want the scan emailed to you or sent on disc? Do you want DICOM? Do you want interactive software? Do you want an additional copy of images printed?) *