First name:

 

Last name:

 

Dental license #

 

Dental license state

-AAAEAKALAPARASAZCACOCTDCDEFLFMGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPRPWRISCSDTNTXUTVAVIVTWAWVWIWY
 

Cell phone:

 

Office phone:

 

Email address

 

Patient's first name:

 

Patient's last name:

 

Patient's DOB:

 

Patients chief concern:

 

Restorative treatment goals:

 

Upload the following diagnostic records. IMPORTANT: The combined size of your files must not exceed 30mb.

For section #'s 4 & 5 - To upload more than 1 image at once, hold "CTRL" to select each file on your computer or select all files. 

1) Panoramic or FMX series (Less than 6 months old)*


2) Maxillary STL file (Less than 8 weeks old)*


3) Mandibular STL file (Less than 8 weeks old)*


4) Intra-oral photographs using retractors: (i) Right and Left biting – must see the first molar occlusion); (ii) center biting; (iii) upper and lower occlusal images*


5) Additional Photos

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