APPT.

TIME______________
CHARGE PATIENT CHARGE OFFICE
CIRCLE ONE: CHARGE PATIENT / CHARGE OFFICE
ADDRESS ____________________________________________________ COST $__________
ADDRESS
(Location where scan will be performed)
Address:

125

Study
Dicom

By signing below, I requested Dental 3D to acquire , review and in.terpret images

the images and Authorization from patient
images
for these procedures.
I understand there is a $50.00 same day Cancellation Fee if I do not cancel myFee
I understand there is a $50.00 same day Cancellation if I do not
appointment cancel my appointment
24 hours
24the
before hours before
scheduled datethe scheduled
payable date.requesting the services.
. by the office

E-Mail: order@dental3dservices.com