DIQUAD, LLC!
Better Image Quality - Lower Patient Dose

Image Upload

Image files must be one of the following types;
jpeg, jpg, bmp, png, tif, pdf, zip, dex

Note: Fields marked with a red asterisk are required!

Image Upload Form

Responsible Dentist Name*

Please enter the Dentist name.

Practice name*

Please enter the Practice name.

Contact Name*

Please enter the Contact name.

Contact Email Address*

Please enter a valid email address for order updates.

Contact Phone#*

Please enter a valid Contact Phone Number in the form '1112223333'.

Facility ID or
Registration Number*

Please enter the Facility ID or Registration Number.

Analyzer Serial
Number*

Please enter the Analyzer Serial Number.

Todays Date*

Please enter Todays Date.

Comments

Please select your test exposure image file: *

Please select a valid image file name.