Submit a Study

Please fill out this form to submit a CBCT study.

"*" indicates required fields

Referring Practice Name*

Practice Email*

Referring Clinician Name*

First Last

Patient Name*

First Last

Patient Date of Birth*

Patient Phone Number*

Clinical Questions and any relevant medical history*

Please write “NIL” if there is nothing significant.

Do you need the report urgently? (within 24-hours)*

No ($100+GST)

Yes ($150+GST)

Please upload your CBCT image below:

1. The image must be in DICOM format.
2. Please ZIP the folder before uploading.
3. Do not close or navigate away from this window before uploading finishes.

Once you click the “Next” button, you will be taken to a payment gate way.

If you have a coupon code, please apply it before proceeding with payment.

File Upload*

Drop files here or

Accepted file types: zip, 7z, rar, Max. file size: 2 GB, Max. files: 2.

I agree with the ACT Dental Imaging Terms of Service.

Please fill out this form to submit a CBCT study.

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