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Bridge in a box Order form USA
Profession
*
Please Select
Doctor
Dental Technician
Name
*
Last Name
First Name
Dental Clinic Name and Address
*
Clinic Name
Street Address
City
State
Zip code
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Country
*
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Email address
*
Case Instruction
Job Due Date
*
-
Month
-
Day
Year
Date
Time
*
Please Select
AM
PM
Dental Clinic Case ID
*
e.g. patient last name - this allows to identify the work precisely back to you
Job order
Details
*
Please Select
Full service (design, mill, sinter, stain and glaze)
Only Mill and Sinter (you provide your stl design)
Number of units in bridge
*
Up to 4 units is possible, for more than 4 units, please send order via Arch in a box Order form
Aesthetic finish level
*
Please Select
Esthetic full countour
High esthetic layered
Custom esthetic high end
Ask TRI rep for more details
Shade
*
Would you like to order a screw at additional cost?
*
Please Select
Yes
No
Number of Screws needed
*
Design Preferences
Mesial/Distal Contacts Distance [mm]
*
Please Select
- 0.40
- 0.30
- 0.20
- 0.10
0.00
Occlusion Distance [mm]
*
Please Select
- 2.00
- 1.50
- 1.00
- 0.50
0.00
Indicate matrix® platform and pontic
Upper arch: Please type "37 or 45" for platform and "P" for pontic
17 (2)
16 (3)
15 (4)
14 (5)
13 (6)
12 (7)
11 (8)
21 (9)
22 (10)
23 (11)
24 (12)
25 (13)
26
(14)
27
(15)
Type:
P37, P45, "P" pontic
Upper arch: For the best milling result possible, please type "37 or 45" for platform and type "2.8L. 2.8 or 2.6" for screw used in your design
17 (2)
16 (3)
15 (4)
14 (5)
13 (6)
12 (7)
11 (8)
21 (9)
22 (10)
23 (11)
24 (12)
25 (13)
26
(14)
27
(15)
Type:
P37, P45, "P" pontic
Lower arch: Please type "37 or 45" for platform and "P" for pontic
47 (31)
46 (30)
45 (29)
44 (28)
43 (27)
42 (26)
41 (25)
31 (24)
32 (23)
33 (22)
34 (21)
35 (20)
36
(19)
37
(18)
Type:
P37, P45, "P" pontic
Lower arch: For the best milling result possible, please type "37 or 45" for platform and type "2.8L. 2.8 or 2.6" for screw used in your design
47 (31)
46 (30)
45 (29)
44 (28)
43 (27)
42 (26)
41 (25)
31 (24)
32 (23)
33 (22)
34 (21)
35 (20)
36
(19)
37
(18)
Type:
P37, P45, "P" pontic
Post-op scans or STL file of your design
*
Browse Files
Drag and drop files here
Choose a file
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of
Patient pictures are helpful for esthetic cases.
Patient photo: Front on, Right side, Left side
Drag and drop files here
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of
Pre-op I/O Scans
Upper, lower, bite scan and existing prosthesis scans
Drag and drop files here
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of
Additional Notes
Total
Credit card information
The credit card will not be charged until the delivery of the job
Total
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Last Name
Credit Card Number
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Promocode
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