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Case Type

Plan Type

ℹ
ℹ
Midcourse Correction
Midcourse correction is the option to order new aligners during treatment, if clinical result have deviated to such an extent that the aligners no longer fit. For Mid-course corrections and/or refinements. we offer free aligners up to 20% of your case total. For example, for 20 aligner case , your are eligible for up to 4 free aligners. Any Midcourse correction or refinements aligners in excess of your free aligner allotment will be $19 per aligner, and no discounts are applicable.
Refinements
Refinements refer to extra trays given to patients who aren’t progressing in accordance with their treatment plan. Refinements will add a couple of extra months to your treatment. For mid-course corrections and/or refinements, we offer free aligners up to 20% of your case total. For example, for a 20 aligner case, you are eligible for up to 4 free aligners. Any mid-course correction or refinement aligners in excess of your free aligner allotment will be $19 per aligner, and no discounts are applicable.
Arch to be treated *
Delivery date *
Impression Type *
Retainer extent *
Upper retainer from to
Lower retainer from to
Any specifications
(Max. 10 files are allowed to Upload)
Arch to be treated *
Impression Type *
Reason*
(Max. 10 files are allowed to Upload)
Arch to be treated *
Impression Type *
Reason*
(Max. 10 files are allowed to Upload)

Case Preferences

Arch To be Treated *
Arch Correction *
Overject *
Overbite *
Midline *
Canine relation
Molar relation
Space alterations
Space Gaining Preference
Upper *
Lower *
Impresion Type
Imprssion Type *
Impression instructions
Tooth movement restrictions (ex. crown, bridges, ankylosed teeth & implants)
Select Crown
Select Implant Crown
Attachment(Do not place attachments on these teeth)
Intra Oral *
Left occlusion

Drop files here to upload

Front occlusion

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Right occlusion

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Maxillary occlusal

Drop files here to upload

Mandibular occlusal

Drop files here to upload

Extra Oral *
Profile

Drop files here to upload

Frontal

Drop files here to upload

Frontal dynamic(smile)

Drop files here to upload

Radiographs
OPG *

Drop files here to upload

Lateral Cephalogram

Drop files here to upload

Upload Any other records (CBCT,etc) (Max. 10 files are allowed to Upload)
Shipping address for the physical Impressions
88 Park Ave Ste 1-A, Nutley, NJ 07110
NOTE
IMPORTANT
Click/print
to be shipped with the impressions
Note
CASE NUMBER:
CUSTOMER NUMBER:
CITY:
STATE:
ZIPCODE:

Special Instructions

(max. 2000 characters allowed)
Case Preview

Office:

Doctor:

Case Type:

Plan Type:

Patient Details

First Name:

Last Name:

Arch to be treated:

Delivery date:

Impression:

Job Design:

Retainer extent:
Upper retainer from
Lower retainer from

Reason:

Files Details
Case Preview

Office:

Doctor:

Case Type:

Plan Type:

Patient Details

Patient No:

Arch to be treated:

Impression:

Job Design:

Reason:

Files Details
Case Preview

Office:

Doctor:

Case Type:

Plan Type:

Patient Details

Patient No:

Arch to be treated:

Impression:

Job Design:

Reason:

Files Details
Case Preview

Office:

Case Type:

Doctor:

Plan Type:

Patient Details

First Name:

Last Name:

Gender:

Age:

Patient Type:

Out Station Date:

Case Preview

Arch To Be Treated:

Arch Correction:

Over Jet:

Over Bite:

Midline:

Cannine Relation:

Molar Relation:

Space Alternations:

space Gaining Preference:

Upper: | Lower:

Selected Tooth