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Doctor Information
Referring Doctor's Name
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First Name
Last Name
Practice Name
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Practice Address
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Street Address
Street Address Line 2
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State / Province
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Practice Phone Number
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Practice Email
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Patient Details
Patient Name
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First Name
Last Name
Case and Prescription Details
Desired Turnaround Time
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Standard
Rush
Tooth Number
Type of Case
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Regular Guide
FP1
FP2
FP3
Prosthetic Type
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Shell
Premade Temporary Crown
PMMA
Full Arch/Stackable
Post-Surgery PMMA
Material Preferences
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Onx
PMMA
Preferred Implant Size
Implant System
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Preferred Planning Responsibility
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Dentist
Lab
Planning Instructions
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Imaging & Model Data
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Upload Intraoral Scan (STL)
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Intraoral Scanner Type
Physical Model?
Tracking Number for Physical Shipment
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Photo Instructions: Zoom #3, eyes into camera, relaxed smile position, and retracted position (using lip retractors).
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Misc
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Compliance, Shipping & Billing
HIPPA Consent
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