Diamond Orthotic Order Form

DOCTOR:

First NameLast Name
PATIENT:

First NameLast Name
Email Address
**NOW REQUIRED** Submission confirmation will be sent to this email; if you receive a confirmation email, then Diamond has successfully received your order form
Is this the patients first device?
CONTACT:

Area CodePhone Number
ADDRESS: Once manufacturing is complete, where should Diamond send the case?

Office Name:

Street Address

CityState

Zip CodeCountry
- Date Received (INTERNAL USE ONLY)
  
  MonthDayYear
- Please explain in as much detail as possible, the nature of the defect/error: i.e. how did the device break? is there no retention on the upper arch? the lower? both?
- Did you return the original models, bite and unalerted device(s) to Diamond with 72 hours of remake claim? REQUIRED for all no-cost warranty claims.
  
  Other
- Please note:
  
  All "no cost" warranty, remake, and repair claims require the original bite, models and unaltered device to be returned to Diamond for evaluation. If the patient is unable to tolerate the absence of their device, Diamond will offer a 25% courtesy discount for the remake.

CASE SUBMISSION

PLEASE SELECT HOW YOU WILL BE SENDING RECORDS FOR THIS PATIENT
PHYSICAL AND/OR DIGITAL RECORDS
Will you be sending a physical bite?
Upload your files ↴ ↴ ↴ ↴

CLICK HERE TO UPLOAD FILES
Upload .STL, PDF files, images, etc.. Cancelof

Vertical Dimensions/Changes to Articulation (Daytime)

Rows	Minimum Speaking	Increase for clearance	Increase Vertical	Decrease Vertical	Protrude	Retrude
mm

Add expansion screw:

Add pontic(s):   Tooth #

Other     Indexing, guidance, etc...
OD Device- Additional Comments/Instructions:
Instructions for Day Device ONLY
(ON) Olmos Night Orthotics - PLEASE SELECT ONE DESIGN:
Select Base Material (NIGHT DEVICE ONLY)

Vertical Dimensions/Changes to Articulation- DDSO

Rows	Increase for clearance	Call if change required	Increase Vertical	Decrease Vertical	Protrude	Retrude
mm

Additional Titration (if needed):

Specific changes to Articulation

Rows	Increase Vertical	Decrease Vertical	Protrude	Retrude
mm

Standard Guards/Splints -

Rows	UPPER ARCH	LOWER ARCH	Base Material	Increase for clearance	Only Cover teeth #'s:	Color:	Other:
Nightguard- Full Occlusion
Occlusal Guard - NTI Type
Occlusal Guard- Slider Type
Michigan Splint Anterior Guidance
Essix Tray
Bleaching Trays
Neurosensory Stent

Sports-Guard Specifications

Rows	UPPER ARCH	LOWER ARCH	Sport	Add logo	Add Patient Name	Sports-Guard Color(s):	Other:
Please Select:

Due Date Requested

MonthDayYear
PLEASE NOTE: All cases will be manufactured according to the production calendar (available for download on our website). Turnaround times can be viewed on page 5 of this form. Manufacturing begins when Diamond receives ALL items required for production; NOT the date the case is sent to the lab.
Doctor Signature
Would you like to rush this case?
RUSH case request:
RUSH case request:
Additional Comments **Note** Writing device selection in this area will delay your case! This area is not for device selection.
Should be Empty:

Please note: