Initial (New) Case "*" indicates required fields Doctor Name* First Last Patient Name* First Last Patient Sex* Female Male Patient Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DentalMonitoring Standard of Care*Remote monitoring by our team of professionals is included in every case and is our standard of care. Monitoring increases compliance and allows us to provide unlimited revisions, unlimited refinements and three retainers on every case at an ultra competitive price. Confirm DentalMonitoring Opt-Out of DentalMonitoring Patient Mobile Number*Required for the DentalMonitoring App. Used only for treatment communications. Provide Now Provide Later Enter Patient Mobile Number*Patient Email Address*Required for the DentalMonitoring App. Used only for treatment communications. Provide Now Provide Later Enter Patient Email Address* Dental Monitoring Opt-Out Consent*Are you sure? By opting out of DentalMonitoring, this case will no longer qualify as MAX SUCCESS which includes unlimited revisions, unlimited refinements, and three retainers. This case will include only one revision/refinement and only one retainer. I Accept and Agree Dental Notation Preference* Universal/American Palmer Arches to Be Treated* Upper & Lower Upper Only Lower Only Teeth to Be Treated* Anterior Only Anterior & Posterior Select Teeth Only Note UPPER TEETH TO BE TREATED with an X23456789101112131415Note LOWER TEETH TO BE TREATED with an X3130292827262524232221201918Note UPPER TEETH TO BE TREATED with an XUR7UR6UR5UR4UR3UR2UR1UL1UL2UL3UL4UL5UL6UL7Note LOWER TEETH TO BE TREATED with an XLR7LR6LR5LR4LR3LR2LR1LL1LL2LL3LL4LL5LL6LL7Class Correction - Requires Elastic Wear* Yes No IPR - Interproximal Reduction or Stripping of Enamel* Only if Recommended No Bite Ramps* Only if Recommended No Attachment Preference*Clear Comfort's heightened gingival coverage and bio-progressive aligners are highly effective in achieving even the most difficult of movements, however, there are cases in which our clinical team might recommend them for optimal efficiency. Only if Necessary No Enter Additional InstructionsMissing Teeth* Yes No Note UPPER MISSING TEETH with an X23456789101112131415Note LOWER MISSING TEETH with an X3130292827262524232221201918Note UPPER MISSING TEETH with an XUR7UR6UR5UR4UR3UR2UR1UL1UL2UL3UL4UL5UL6UL7Note LOWER MISSING TEETH with an XLR7LR6LR5LR4LR3LR2LR1LL1LL2LL3LL4LL5LL6LL7Would You Like to Use Pontics for Missing Teeth?*Additional cost of only $3.00 per pontic/per aligner. Yes No Note Desired UPPER PONTICS with an X23456789101112131415Note Desired LOWER PONTICS with an X3130292827262524232221201918Note Desired UPPER PONTICS with an XUR7UR6UR5UR4UR3UR2UR1UL1UL2UL3UL4UL5UL6UL7Note Desired LOWER PONTICS with an XLR7LR6LR5LR4LR3LR2LR1LL1LL2LL3LL4LL5LL6LL7Tooth Shade for Pontics* Light Medium Dark Existing Dental Work* Yes No Note Type of Dental Work on Involved UPPER TEETH (I = Implant, V = Veneer, C = Crown, B = Bridgework)23456789101112131415Note Type of Dental Work on Involved LOWER TEETH (I = Implant, V = Veneer, C = Crown, B = Bridgework)3130292827262524232221201918Note Type of Dental Work on Involved UPPER TEETH (I = Implant, V = Veneer, C = Crown, B = Bridgework)UR7UR6UR5UR4UR3UR2UR1UL1UL2UL3UL4UL5UL6UL7Note Type of Dental Work on Involved LOWER TEETH (I = Implant, V = Veneer, C = Crown, B = Bridgework)LR7LR6LR5LR4LR3LR2LR1LL1LL2LL3LL4LL5LL6LL7Panoramic X-RayRecommended Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 1 GB. Cephalometric X-RayRecommended Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 1 GB. Profile PicturesRecommended - front relaxed, front smiling, right side profile relaxed Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 1 GB. Intraoral PicturesRecommended - frontal, right buccal, left buccal, upper arch, lower arch Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 1 GB. Model Type*NOTE: Both an upper & lower intraoral scan, PVS impression, or stone model are required for all case submissions Intraoral Scans (STL Files) PVS Impressions Stone Models Scanner Used* Trios iTero Omnicam Primescan Carestream Heron Medit 3M Planmeca Other Upload Intraoral Scans Drop files here or Select files Accepted file types: stl, dcm, stl, dcm, Max. file size: 1 GB. Need a Prepaid Shipping Label for Impressions/Models?* Yes No Email Address for Sending Shipping Label* Production Priority*Normal production time is approximately 2 weeks from the time the SmileDesign is accepted. Normal RUSH ($250 Additional Fee) Requested RUSH Delivery Date for AlignersMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ship To:* Office Address Patient Address Office Shipping Addres* Amarillo - 7901 SW 45th Ave, Amarillo, Texas 79119 Canyon - 2808 4th Ave., Suite B, Canyon, TX 79015 Colonies - 4515 Van Winkle Dr., Amarillo, TX 79119 Dalhart - 219 E. Texas Blvd., Dalhart, TX 79022 Dumas - 315 E. 2nd St., Dumas, TX 79029 Georgia - 3609 S. Georgia Street, Amarillo, TX 79119 Hereford - 809 W Park Ave., Hereford, Tx 79045 North Grand - 2201 North Grand, Amarillo, TX 79107 Prosper - 821 N Coleman Street, #110, Prosper, TX 75078 Patient Shipping Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Confirmation of Upper & Lower Scans, Impressions, or Models*Both the U & L scans, models, or impressions have been taken and will be included in the case submission Yes Confirmation of Informed Consent & Agreement*The patient has signed or will sign the Clear Comfort Informed Consent & Agreement found in the Doctor Info section of this website Yes Consent to Terms of Use & Service and Privacy Policy*I accept and agree to the Clear Comfort Terms of Use, Terms of Service, and Privacy Policy found in the About Us section of this website Yes Δ
