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131 McDowell Street | Asheville, NC 28801 | 828-254-4602
Biltmore Park | 1Town Square Blvd | Asheville, NC 28803| 828-684-5498
consultation
sursmile
damon system
radiance
invisalign
TS Orthodontics
GP and Specialist referral form
What is i-CAT?
|
GP and Specialist referral form
Patient Name:
Referred by:
Referrer's Email Address:
Also send to Doctor:
Doctor's Email Address:
Protocol:
Xoran
Dicom Single-File
Dicom Multi-file
iCAT Vision
Indicate if using Noble Guide
Scan of Patient
Scan of Patient (w/ appliance inserted)
Separate scan of Appliance
Reason for Referral:
Pathology
Surgery
TMJ
Implant
Extraction
Other
Indicate Site:
ICD-9 Diagnosis:
Comments:
Verification Code:
(case sensitive)
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