Doctor Name
*
Patient Name
*
Email
*
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is fabricating the prosthesis?
Please Select
Doctor's Office
ROE Dental Laboratory
Arch
*
Please Select
Upper
Lower
Both Arches
Tooth Shade
*
Please Select
None
A1
A2
A3
B1
B2
BL3
Tissue Shade
*
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Pink
Light Pink
Dark Pink
Prosthetic design preference
*
Please Select
FP3 (standard with pink)
FP2 (longer teeth)
FP1 (tooth only no pink)
Screw Brand
*
Please Select
Vortex 1.4mm Direct to MUA
Vortex 1.6mm Direct to MUA
Vortex 1.72mm Direct to MUA
BioHorizons Direct to MUA
DESS 19.018
DESS 19.069 - Straumann
Dan Rosen 1.4mm
Dan Rosen 1.6mm
Dan Rosen 1.72mm
Nobel Temp Screw
SEG
SIN
Include Screws?
*
Please Select
Yes
No
Do you need a driver?
*
Please Select
Yes
No
How are you submitting your files?
*
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All STLs and photos are being submitted via this form
SLOWER PROCESS - Scans submitted via IOS and photos are being submitted via this form
IOS Portal
*
Please Select
Medit Link
Primescan Sirona
Trios
Virtuo Vivo (Straumann)
Shining 3d Aoralscan 3
Other (ROE is not responsible for accuracy)
Name of other IOS
Case Notes
Patient Records
*
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