Encode RX
Doctor
*
First Name
Last Name
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
Phone Number
*
-
Area Code
Phone Number
Location
*
Delivery Date By 5pm
*
-
Month
-
Day
Year
Date
Upper Scan STL
*
Browse Files
Cancel
of
Lower Scan STL
*
Browse Files
Cancel
of
Bite Scan STL
Browse Files
Cancel
of
Shade
*
Impressions/Models
*
Models / Impressions will be / have been mailed
Digital Scan
Both Models/Impressions will/have been mailed AND Digital File attached to this form
None - Full Edentulous Both Arches
Healing Abutment Part Number
*
Photographs - Retracted | High and Low Smile| Profile
Upload Files
Cancel
of
If you are a new customer please select yes and fill in the following
Yes
No
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Coupon Code
Agree to terms and conditions of order
*
I have read, understand and agree to the terms and conditions of ordering products using this form.
Submit
Additional Notes
Should be Empty: