Tat-Tooth Case Upload
Doctor
*
Frazelle
Phone Number
*
Area Code & Phone Number
Email
example@example.com
Patient Identification Code (PIC)
*
12345Required 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
Deborah
McQuery
Upload Desired Tat-Tooth Image Here
*
Browse Files
Shift+Click or Ctrl+Click to select multiple files
Cancel
of
Shade
Notes
Please Upload Rx Form with Scans
Lab Location
*
Durham/Greensboro
Charleston
Wilmington
Submit Order
Should be Empty: