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www.Scansmiles.com
E-mail: 3D@Scansmiles.com
113 Olympus Drive, Ocoee, FL 34761
3D CAD Aligners
Palm Ortho Lab License# DL11529
RX
| 2018
Digital RX
DOCTOR INFORMATION
Doctor
*
Doctor Phone
*
Doctor Email Address
*
Doctor Signature
*
Please type your full name to certify. (required)
License #
*
Address
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
PATIENT INFORMATION
Patient Name
*
Date of Birth
Sex
Male
Female
ADDITIONAL INFORMATION
Please Send
Prescription Forms
Please Send
Shipping Boxes
Please Send
Shipping Labels
Additional Instructions
Sending STL files
Additional Instructions
Sending Models or Impressions
Additional Instructions
Please call concerning this case or Set Up
CASE INFORMATION
Upper Midline
Correct
Right
(mm)
Left
(mm)
Overjet
(mm)
Overbite
(mm)
Molar Relationship
Class I
Class II
Class III
Canine Relationship
Class I
Class II
Class III
Crossbite
Right
Left
Anterior
Proclined
Inclined
FABRICATION OPTIONS
IPR: The best IPR method is to apply at each appointment where space is desired and access allows. If floss can not pass easily, apply IPR to allow teeth to move. This method will give the appropriate IPR as treatment progresses towards a great smile.
IPR
Do Not Apply IPR
IPR
Apply IPR As Needed
IPR
Do Not Use Attachments
IPR
Minimal As Necessary
IPR
Relieve Tray For Bonded Buttons
IPR
Expand Arch
IPR
Do Not Expand Arch
PRODUCT OPTIONS
Product Options
3D CAD Aligners (includes Set Up)
Set Up To Be Approved
Product Options
Fabricate Trays Without Approval
Number of Initial Trays
Product Options
10 Sets of Trays
Product Options
Set Up and Print 3D Models
(for Dr Fabricated Trays)
Product Options
3D Patient Records File
Product Options
Revision
Product Options
Clear Retainers
CASE OBJECTIVES
CASE OBJECTIVES
Upper Arch
Lower Arch
CASE OBJECTIVES
Full Treatment
CASE OBJECTIVES
Straighten Teeth Indicated
CASE OBJECTIVES
Straighten Anteriors Only
CASE OBJECTIVES
Correct Intrusions / Extrusions
CASE OBJECTIVES
Straighten Incisors to Ideal
CASE OBJECTIVES
Improve Midline
CASE OBJECTIVES
Improve Overjet
CASE OBJECTIVES
Improve Overbite
CASE OBJECTIVES
Incline Anteriors
CASE OBJECTIVES
Procline Anteriors
CASE OBJECTIVES
Improve Arch Form
SPECIAL INSTRUCTIONS
Special Instructions
RESET THESE TEETH
Checkboxes
Reset Anteriors Only
Reset Incisors Only
RIGHT UPPER
LEFT UPPER
RIGHT LOWER
LEFT LOWER
DO NOT MOVE THESE TEETH
Checkboxes
Do Not Move These Teeth
RIGHT UPPER
LEFT UPPER
RIGHT LOWER
LEFT LOWER
DO NOT USE ATTACHMENTS ON THESE TEETH
Checkboxes
Do Not Use Attachments On These Teeth
RIGHT UPPER
LEFT UPPER
RIGHT LOWER
LEFT LOWER
Submit
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3D Aligners
3D Treatment
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Contact
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Digital Rx
407.719.9899
3D@scansmiles.com
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