Submit a Study

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.

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

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File Upload *

Click or drag a file to this area to upload.

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https://actdentalimaging.com/terms-of-use/

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