Patient Referral for Galileos Conebeam CT

We would be happy to take a Conebeam CT of your patient to aid you in the most accurate diagnosis.  Please fill out the following referral slip for your patient and we will contact your patient to schedule a scan at their convenience.

Patient Charge: $385 for cone beam CT capture and interpretation with field of view of both jaws.  We can check your patients' insurance benefits to help determine their estimated cost.

Referring Provider Charge: $0

Provider Phone Number *
Provider Phone Number
Patient Name *
Patient Name
Patient Contact Number *
Patient Contact Number
Date Patient First Reported Symptoms *
Date Patient First Reported Symptoms
Reason for Scan *
Please include detailed information - tooth # / area of arch / current condition / information you would like to obtain from CT

 

Our Office

480 Ansley Drive
Saint Joseph, MI 49085
USA

269.428.4700