Imaging Service PrEscription Form

Practice Name:
Address:
City:
State:
Zip:
Imaging Information
Patient Name:
Note: Please ensure all file names do not include any special characters to include periods, hyphens, or underscores and the file sizes are smaller than 5MB prior to uploading them to this site.
Upload Image (frontal):
Upload Image (lateral):
Upload Image (full face):
Treatment Plan: (Please specify teeth to image here)
Shade Desired:
Do you desire balance of gingival tissue?
By checking this box I agree that to my knowlege the above information is accurate:

Request demo

Request an online demonstration with your own photograph and we will image it right in front of you! Let us show you the power of imaging!