Doctor's Referral

Referral Form for CBCT Scans










Give scan to patientBurn to disk, Send by mailBurn to USB drive, Send by mail

Centric occlusionTeeth apartWith implant guide appliance or splint in place (must be provided)Implant guide appliance or splint by itself (must be provided)

MaxillaMandibleBoth JawsURULU AntLRLLL Ant

ImplantSurgeryExtractionPathologyEndodonticsOther


Fee for CBCT Scan

The patient will be expected to pay for the service at the time the scan is obtained. The fee for the scan is $160 for a sectional scan, $230 for a Single Jaw scan and $350 for both jaws scan. Multiple scans may be required if the purpose of the CBCT scan is for implant placement.

Radiographic Interpretation

The scans we provide are offered as a service, which is not read nor interpreted by Dr Keith Chiang. The scan will be sent to your office in the DICOM file format. Interpretation of the data contained within the scan file is the sole responsibility of the referring dentist and you can choose to further refer on as you deem fit.

The patient will have the option to have the scan read by an Oral and Maxillofacial Radiologist for an additional fee or they may waive the right to this service. Dr. Keith Chiang strongly recommends having the scan interpreted by an Oral and Maxillofacial Radiologist and we offer that with the help of an overseas Oral and Maxillofacial Radiologist. If the patient requests this additional service, our office will send a copy of the scan to our overseas colleague, who will read the scan and email a report on their findings to the referring dentist. Follow-up on the results of the scan interpretation will be the sole responsibility of the referring dentist. The fee for this additional service is $110.00 with a standard turn-around time of 3-5
business days.

The patient requests to have the CBCT scan read by an Oral and Maxillofacial Radiologist and understands that they are responsible for additional costs. The patient will be responsible for the appropriate fee to include the requested CBCT scan with the radiology report. The oral radiology report will be emailed to the general dentist.No, the patient understands the risks and benefits of having their CBCT scan read and interpreted by an Oral and Maxillofacial Radiologist; however, they knowingly decline the referral. The patient will be responsible for the total fee to include the CBCT scan without the radiology report.

General CBCT Information and Patient Consent Forms

Links for general CBCT information for patients and our CBCT patient consent form can be found under the Contact Us link located at the top of our menu bar on the right side of our website. Once the page is open, please look at the bottom right and click on the link CBCT. Please encourage patients to access this information and review it before their appointment in our office.

I have read, understand and agree to the above terms for CBCT services

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