DSD/Digital Wax Up
Doctor Name
*
First Name
Last Name
Patient Name
*
Patient Sex
Male
Female
Due Date
*
-
Month
-
Day
Year
Date
Appointment Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Has this patient committed to treatment?
*
Yes
No
Items Sent
Digital Impression
*
CareStream
Cerec
Itero
Medit
Trios
Other
No scan sent
Analog Impression
*
Yes
No
Photos sent
*
Email - caseentry@midwestdentalarts.com
Dropbox
Attached below
Work Requested
*
Motivational (2D) mock-up completed using computer software (DSD APP) $100 (48 hour). Full face smile with teeth slightly apart preferred.
Motivational (3D) mock-up. This is an additive only digital wax up to motivate the patient to accept treatment. 3D models and temporary matrices will be fabricated. $35 per tooth plus $30 for printed models and matrices.
Functional/esthetic digital diagnostic wax up. This is a digital wax up done using a scan of the patient. $35 per tooth plus $30 for printed models and matrices.
Custom shell temporaries. Milled temporaries based on the functional digital wax up. $60 per tooth. Optional custom seat jig $175 per arch.
Review before printing required?
*
Yes
No
Shell Temps Shade Selection
Tooth Number and Design (Upper)
*
Crown
Veneer
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Full Upper Arch
Tooth Number and Design (Upper)
Crown
1
2
3
4
5
6
7
8
9
10
Veneer
1
2
3
4
5
6
7
8
9
10
Tooth Number and Design (Lower)
*
Crown
Veneer
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Full Lower Arch
How was the bite taken?
*
At an open vertical
Centric Relation (CR)
Centric Occlusion or MIP
Other
Digital Crown Lengthening guide
*
Yes
No
Additional Information
Full Face Exaggerated Smile Photo
*
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Full Face Retracted Photo
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Full Face Repose Photo
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Profile View - At Rest Photo
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of
Profile View - Smiling Photo
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of
12 O'Clock Photo
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Close Up View - Smiling Photo
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of
Close Up - Retracted Photo
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Signature
*
Upload photos or additional information here
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of
Please send more:
Boxes
Lab Scripts
Shipping Labels
Shipping Bags
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