Holliday Ortho: DIBS Lab Slip
Patient's Name
*
First Name
Last Name
Patient's ID
*
Scan Date
*
-
Month
-
Day
Year
Date
Scan ID
*
Treating Doctor
*
Dr. Holliday
Dr. Brad
Dr. Sheri
Dr. Kimura
Dr. Ferguson
Scan Location
*
Pearl City
Kailua
Honolulu
Kahala
Scan Sent to OrthoSelect on Itero
*
Yes
No
Clinical Assistant Initials
*
Which arches will be bonded?
*
Maxillary
Mandibular
Both
Any teeth that are missing or will be extracted?
*
Any Space that we need to keep open?
*
Mixed Dentition?
*
Yes
No
Which Brackets will be bonded
Upper Norris (DynaFlex Norris 20-26 U & L 5-5)
Lower Norris (DynaFlex Norris 20-26 U &L 5-5)
Upper Damon Clear (Ormco Damon Clear2 and Clear Ceramic U 5-5)
Damon 6's (RMO FLI Non-Conv. Tubes U & L 6's)
Norris 6's (Dyan Flex Norris SL Tubes U & L 6's)
Upper Regular 7's (RMO FLI Non-Conv. Tubes U & L 7's)
Lower Mini Tubes 7's (RMO FLI Non-Conv. Mini Tubes L7's)
Additional Comments
Submit
Should be Empty: