Dental Imaging Prescription Submission

NOTICE: We have temporarily replaced our webform Rx with a downloadable PDF.

DOWNLOAD Rx (recommended)
Right-click (Ctrl-click on the Mac) here and save the PDF to your desktop for completion and submission as an e-mail attachment (or print and fax).

You may also complete the PDF in your web browser by clicking here. However, please remember to save a completed copy in your local database and send a copy to us as an e-mail attachment (or print and fax).

IMPORTANT: Before completing online, make sure you have Adobe Reader (the latest free version is availablehere). Some Windows users may also need to update file type association settings
to make Adobe Reader the default program for handling PDF files:

1. Click “Start”
2. Open “Control Panel”
3. Double-click “Folder Options”
4. Click “File Types” tab
5. Locate PDF extension in “Registered File Types” list
6. Verify that Adobe Reader is the associated file type.
7. If Adobe Reader is not the program listed for handling PDF files,
click PDF in the list and then click on the “Change” button
to update your settings.

Once a completed form is saved in your local database, it may be sent via your preferred method of contact to the appropriate lab from the options below:

dental x rays submit prescription

Fax: (425) 450-5605

Fax: (206) 528-2929