Retainer Purchase Submission Form

Retainer Purchase Submission Form

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Set of Retainers:

First name:

Last name:

Dental license #

Dental license state

Cell phone:

Office phone:

Email address

Patient's first name:

Patient's last name:

Patient's DOB:

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

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

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

After submitting do not close this window until you see the confirmation page.