THIS SITE IS CURRENTLY UNDERGOING MAINTENANCE
During this time, the referral forms may not funciton as expected.
Estimated Completion: 3:00pm EST

Cone Beam CT Referral

Only scans with interpretation are available through this form at this time.

1. Doctor Information

(required)
letters, spaces, hyphens, apostrophes
(required)
letters, spaces, hyphens, apostrophes
(required)
letters, spaces, hyphens, apostrophes

numbers only, 10 digits required, or 15 if using prefix 80840
(required)
numbers, hyphens
(123-123-1234)

(required)
numbers, letters, hyphens, apostrophes
(name@example.com)

(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
Only U.S. States are currently available
(required)
numbers, hyphen
(format: 12345 or 12345-6789)

Click the blue button to save currently entered referring doctor information, so that it loads automatically next time.
To overwrite previously saved information, enter new information and click save again.

2. Patient Information

(required)
letters, spaces, hyphens, apostrophes
(required)
letters, spaces, hyphens, apostrophes
(required)
numbers, hyphens (ex: 01-25-1997)

optional
(required)

numbers, letters, hyphens, apostrophes

numbers, letters, hyphens, apostrophes
(required)
please select one

numbers, letters, hyphens, apostrophes
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
Only U.S. States are currently available
(required)
numbers, hyphen
(format: 12345 or 12345-6789)

(required)
numbers, hyphens
(123-123-1234)


numbers, letters, hyphens, apostrophes
(name@example.com)

3. Details

Reasons for Scan


Region and Field of View


Scan Options

Image Data Output


Other Referral Comments

Appointments are made through Dental Faculty Associates Perio (DFA Perio) (734-764-2700).
Patient should report to DFA (room 3370, third floor, School of Dentistry) 30 minutes before appointment to register.
Registration material will be sent to the patient in advance if there is enough time before the appointment.

Erika Benavides, DDS, PhD
Diplomate, American Board of Oral and Maxillofacial Radiology
Fabiana Soki, DDS, MDSc, PhD
University of Michigan School of Dentistry Dental Faculty Associates
1011 N. University Avenue, Room 3370, Ann Arbor, MI 48109-1078
Tel: 734-764-2700