General Rx Information
Doctor Name
*
Patient Name
*
Patient Age
Patient Gender
Male
Female
Email
*
Phone Number
*
Format: (000)-000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Transition Design
*
Copy Try-In Design Exactly
Custom (Indicated on the Right)
Custom Transition
*
Hygienic w/ Ridge Contact - Upper
Hygienic w/ Ridge Contact - Lower
Highwater/Open Ridge - Upper
Highwater/Open Ridge - Lower
Maxillary Flange - Upper
Maxillary Flange - Lower
Bite Class
*
I
II
III
Tooth Number To Omit
*
Implant Brand
*
Please Select
3i T3 Zimvie
Adin Closefit
Adin Touareg
Astra TX (requires OEM parts)
Astra EV (requires OEM parts)
Ankylos
BHI
Bicon (requires OEM parts)
BioHorizons Fusion
BioHorizons Pro Conical
BioHorizons Tapered Pro Conical
BioHorizons Tapered Internal
BioHorizons Tapered Plus
BioHorizons Tapered Pro
BlueSkyBio
Camlog (requires OEM parts)
ConeLog
Dentis
DIO
Ditron Molecular
Ditron Precision
Frialit (requires OEM parts)
Hahn
Hiossen
Implant Direct
InnoBioSurg (requires OEM parts)
Keystone Genesis TriLobe
Keystone Genesis Active
Keystone Prima Plus
Keystone Prima
MIS SEVEN (requires OEM parts)
MIS C1 XD (requires OEM parts)
Megagen AnyRidge
Megagen Blue Diamond
NeoBiotech (requires OEM parts)
NeoDent Helix
NeoDent GM
Neodent Drive
Neoss (requires OEM parts)
Nobel Biocare Active
Nobel Biocare N1
Nobel Biocare Parallel
Nobel Biocare Replace
Noris Medical
OCO Biomedical
Paltop (requires OEM parts)
Ritter
SIN
Southern Internal Tapered
Southern DC CO-A CoAxis
Southern Tri-Nex
Southern Other
Straumann BLT
Straumann BLX
Straumann TLX
Tag
Thommen
Xive (requires OEM parts)
Zimvie TSV
Zimvie TSX
Zimvie Trebecular
Zimvie T3 Pro Tapered
Other, indicate in Notes
Implant Line/Platform
*
Due Date
*
-
Month
-
Day
Year
Date
I need shipping supplies
Yes
Expedite (fees apply)
Yes
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Tooth Shape
For Tooth Shape Use
*
Enclosed Photos (see file upload field before submit button)
Use Smile Catalog (see below)
Use Study Model
Use Bespoke Shape (see below)
Other (see below)
Smile Catalog
Smile Name
Other
Image Checkboxes
*
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Tooth Shade
Choose the desired tooth shade below
*
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Tooth Intensity
Choose the desired tooth intensity below
*
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Tooth Texture
Choose the desired texture below
*
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Gingival Hue
Choose the desired Gingival Hue below
*
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Gingival Texture
Choose the desired Gingival Texture below
*
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Material
Choose the desired material below
*
Please Select
TLZ-IB Zirconia w/ Ti Bases
TLZ-IB Zirconia w/o Ti Bases (require Nobel-compatible MUAs only)
NobelProcera Zirconia (require Nobel-compatible MUAs only)
G-CAM
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Final Notes
Instructions
License #
*
Photos For Tooth Shape
Browse Files
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