Will a dental stent be provided? Yes No

Appointment for Diagnostic Imaging Exam Date: ________ Check-in Time: ________

Patient Information:Name: _______________________________________ Phone: ______________ SSN: ___________

Insurance: ____________________________________________ Date of Birth: _____/_____/_____Please bring this form and your medical and dental insurance billing information.

Exam Information:Exam Ordered:

CT Maxilla $375CT Mandible $375CT Mandible and Maxilla $750

Clinical:

425.656.5550 ph. See map and directions on back 425.656.5552 fax

ImagesDICOMM format CDFilms

Simplant View CD:_______________________Other__________________________________

Simplant CDSimplant CD w/1xSoftware ($200 One-shot)

Fax Final reportMail/ Courier Final report

Referring Doctor Signature: __________________________________________________________

Physician Information:Referring Doctor: ____________________________ Phone: _______________ Fax: ______________

Next Appointment with the Doctor: ______________________________________________________Planning Software Used: Simplant Nobel Guide VIP None Other: _______________

Report/ Image Preference:Reports

Phone Prelim reportFax Prelim reportCC to Dr: ________________________________

733.03 Evaluate for Disuse Osteoporosis733.7 Evaluate for Disuse Atrophy478.19 Pneumatization of the Sinus733.99 Evaluate for Foreign Body in the bone526.4 Inflammation of the Jaw (Abscess,Osteomyelitis, Sequestrum)521.4x - Evaluate for bone resorption

526.5 Alveolitis of the Jaw (Infection in thetooth socket)733.01Osteoporosis, post-menopausal793.0 Abnormal findings on radiologic exam,head/skullOther/Signs/Symptoms:_________________________________________________________

400 S. 43rd St, Renton, WA 98055 •• 425.656.5550 Ph. •• 425.656.5552 Fax •• www.vrads.com

Valley Radiologists, Inc. P. S. in association with Valley Medical Center

Directions from the North: From Hwy. 167 take SW 41st Street exit Take a left onto E. Valley Road Take a left onto SW 43rd Street Take a left onto Talbot Road South Take a left into 3rd driveway on the left. Follow down the hill and around the back of the Valley Medical Center campus

Valley Diagnostic Imaging Services- Olympic Building is located on the back of the campus facing West.

CT:A CT, computerized tomography scan is a special examination in which multiple “slices” or pictures are taken through an area of the body. You will be placed on a table which will move you into the scanner. After each “slice” is taken the table will move a small distance to take the next picture. CT scanning for dental imaging is non-invasive and takes less than 30 minutes. Actual exam time is approximately 10 minutes.

CT Preparation: No preparation necessary. Please bring your dental stent if it was provided to you by your referring physician.

Directions from the South: From Hwy. 167 take SW 43rd St. exit Take a right onto SW 43rd St. Take a left onto Talbot Road South Take a left into 3rd driveway on the left. Follow down the hill and around the back of the Valley Medical Center campus

Valley Diagnostic Imaging Services- Olympic Building is located on the back of the campus facing West.