rx – Scansmiles

DOCTOR INFORMATION

Doctor *

Doctor Phone *

Doctor Email Address *

Doctor Signature *

Please type your full name to certify. (required)

License # *

Address

City

State/Province

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

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

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