Initial (New) Case "*" indicates required fields Doctor Name* First Last Patient Name* First Last Patient Sex* Female Male Patient Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Mobile Number*Used Only for DentalMonitoring CommunicationsPatient Email*Used Only for DentalMonitoring Communications Arches to Be Treated* Upper & Lower Upper Only Lower Only Enter Additional InstructionsMissing Teeth* Yes No Note UPPER MISSING TEETH with an X23456789101112131415Note LOWER MISSING TEETH with an X3130292827262524232221201918Existing 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)3130292827262524232221201918Panoramic 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 PVS impressions or stone models are required for all case submissions PVS Impressions Stone Models Need a Prepaid Shipping Label for Impressions/Models?* Yes No Email Address for Sending Shipping Label* Ship Aligners To:* Office Address Patient Address Office Shipping Address* Airline - 4701 Airline Dr, Houston, TX 77022 Atascocita - 7112 Farm to Market 1960 Rd E, Humble, TX 77346 Baytown - 6502 Garth Rd, Suite 100, Baytown, TX 77521 Beaumont/Atascocita - 4105 Dowlen Rd Ste. A, Beaumont, TX 77706 Bissonnet - 9533 Southwest Fwy, Houston, TX 77074 Conroe - 1317 W Davis St Ste. D, Conroe, TX 77304 Corpus - 4901 S Padre Island Dr, Corpus Christi, TX 78411 FM1960 - 12711 Farm to Market 1960 Rd W, Houston, TX 77065 Fry Rd - 19961 Katy Fwy, Houston, TX 77094 Gulfgate - 995 Gulfgate Center Mall, Houston, TX 77087 Haven - 3745-A Westheimer Rd, Houston, TX 77027 Humble - 20135 Highway 59 North, ste a, Humble, TX 77338 Hwy 6 - 3402 S Texas 6 Houston, TX 77082 Katy Mills - 1998 Katy Mills Blvd STE. D, Katy, TX 77494 Louetta - 10123 Louetta Rd #900, Houston, TX 77070 Meyerland - 650 Meyerland Plz, Houston, TX 77096 Missouri City - 6245 South, 6245 Hwy 6 #400, Missouri City, TX 77459 North Heights - 2401 N Shepherd Dr Ste. 160, Houston, TX 77008 Pasadena - 5681 Fairmont Pkwy Ste. B, Pasadena, TX 77505 Pearland - 11302 Broadway St #104, Pearland, TX 77584 Splendid Richmond - 3991 Richmond Ave., Houston, TX 77027 Springwood - 2156 Spring Stuebner Rd, Spring, TX 77389 Webster - 304 Bay Area Blvd Ste. 300, Webster, TX 77598 West U - 5230 Buffalo Speedway Suite B, Houston, TX 77005 Westheimer - 8570 Westheimer Rd, Houston, TX 77063 Yale - 174 Yale St # 1200, Houston, TX 77007 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 impressions or stone models 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
