New Appliance Scan / Impression

New Appliance Scan / Impression
Assistant*
Patient ID*
Appliance Due Date*

MonthDayYear
For appliances sent to other labs = todays date, For appliances made IN HOUSE = 2 business days before next appointment.
Outside Lab Appliances

Mx HawleyMd HawleyGlidewell SplintMARPE/MSEHerbstMARARPE (Bondable)Other
Bondable Expander Design

E1 (Ph1 U6s)E2 (Perm U6s)E3 (Ph1 UEs)E4 (Ph1 Lower)
In-House Lab Appliances

Mx Clear RetainerMd Clear RetainerPremium Retainer PackageFixed RetainerAlignersIDB TraysDiagnostic Setup (ULAB)Bleaching TraysMotion ApplianceSports MouthguardPrint Model
Mx Clear Retainer Bite Ramps

Bite Ramps U1sBite Ramps U2-2
Fixed Retainer Type
Mouthguard Color
Patient Phone Number for Mouthguard
Please enter a valid phone number.
Upper Braces*

Silver UpperClear UpperDamon Silver UpperDamon Clear UpperGold Upper
Lower Braces*

Silver LowerClear LowerDamon Silver LowerDamon Clear LowerGold Lower
Which model to print?

UpperLower
Notes:
Should be Empty: