Removable Case Upload
Doctor
*
Phone Number
*
Area Code & Phone Number
Email
example@example.com
Practice Branch
*
Please include location
Patient Identification Code (PIC)
*
Required for case communication to maintain HIPAA compliance. Please enter existing PIC (already used within your office). Or Create a 5-7 digit code (alpha & numerical) Example: Pt. John Doe = D13578
Patient Name
First Name
Last Name
Upload Rx and Digital Scan
*
Browse Files
Shift+Click or Ctrl+Click to select multiple files
Cancel
of
Select What You Are Submitting
Submit New Case
Upload Patient Photos
Add Information to a Digitally Uploaded Case
Add Information to Existing Analog Case
Shade
Please Upload Rx Form with Scans
Type of Case
*
Acrylic
Carbon Flex
Carbon Clear
Metal Partial Frame
Add Bite Rim
Add Tooth Try-In
Designed Denture for Printing
Digital Denture Try-In
Digital Denture Process
Digital Only 3D Partial
Duraflex Partial
FP3D Digital Partial
Copy or Backup Denture
Immediate Denture
Bite Rims
Custom Tray
Reline
Essix Retainer
Nightguard
Bleaching Tray
Panthera Sleep Appliance
SportsGuard or Custom SportsGuard
If sending additional items via mail, check this box
None of the above apply RX uploaded with instructions
Other
Type of SportsGuard
*
SportsGuard
Custom SportsGuard
SportGuard Color
Please Select
White
Black
Upload Jpeg for Custom SportsGuard
*
Browse Files
Cancel
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Lab Location
*
Durham/Greensboro
Charleston
Wilmington
Additional Notes
Intraoral Scans
*
Please Select
Uploading Models on Web
Uploading via Sirona
Uploading via Itero
Uploading via Trios
Uploading via DEXIS Connect
Uploading via CS Connect
Uploading via Endossier
Uploading via Medit
Sending Stone Models or Impressions
No Scan
Will you be sending any analog parts to pair with this case?
*
Please Select
Yes
No
Return Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Order
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