Crown and Bridge Case Upload
Doctor
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Patient Identification Code (PIC)
*
Required for case communication to maintain HIPPA compliance. Please enter existing PIC (already used within your office). Or Create a 5-7 digit code (alpha & numerical) Example: Pt. John Doe = D13578
Patient Name
First Name
Last Name
Upload Rx and Digital Scan
*
Browse Files
Shift+Click or Ctrl+Click to select multiple files
Cancel
of
Notes
Please Upload Rx Form with Scans
Submit Order
Should be Empty: