CM AoX Order Form
Email
*
example@example.com
Practice name
*
Contact Person
*
First Name
Last Name
Phone Number
*
Scan Type?
*
Please Select
1) Digital Scan
2) Stone Model (+AUD 80+GST for scanning)
File Upload
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Design instruction
*
Long Term Provisional - 3D Printing
*
Resin/Shade
Any instruction
Upper
A1
A2
B1
Lower
A1
A2
B1
Substructure - MUA Type and Location
*
Tooth No.
MUA Type
Remarks
Upper
Nobel MUA 4.8
Others
Lower
Nobel MUA 4.8
Others
Others
Nobel MUA 4.8
Others
Supra Structure - Zirconia Instruction
*
Teeth Shade
Gum Shade
Any instruction
Upper
BL1
BL3
A1
A2
A3
B1
B2
C1
C2
Light pink
Medium Pink-Red
Dark Red
Lower
BL1
BL3
A1
A2
A3
B1
B2
C1
C2
Light pink
Medium Pink-Red
Dark Red
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