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Referring Practice Name *

Practice Email *

Referring Clinician Name *

First

Last

Patient Name *

First

Last

Patient Date of Birth *//

Patient Phone Number *

Clinical Question (and any relevant medical history) *

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

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.

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