Crown and Bridge 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
Select What You Would Like to Submit
*
Submit New Case
Upload Patient Photos
Add info to digitally uploaded case
Add info to existing analog case
Other
Upload Rx, Photos, Tat-tooth Images, or Digital Scan
*
Browse Files
Shift+Click or Ctrl+Click to select multiple files
Cancel
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Notes
Type of Case
*
Tat-tooth
Adzir
Envision
Zirconia Hybrid
Implant
PFM
Emax
Other
Please Upload Rx Form with Scans
Will you be sending in any analog parts to pair with this case?
*
Please Select
Yes
No
Return Date
*
-
Month
-
Day
Year
Date
Lab Location
*
Durham/Greensboro
Charleston
Wilmington
Submit Order
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