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*Required for the DentalMonitoring App. Used only for treatment communications.Patient Email*Required for the DentalMonitoring App. Used only for treatment communications. 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 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 XUR7UR6UR5UR4UR3UR2UR1UL1UL2UL3UL4UL5UL6UL7Note LOWER MISSING TEETH with an XLR7LR6LR5LR4LR3LR2LR1LL1LL2LL3LL4LL5LL6LL7Existing Dental Work* Yes No Note 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 upper & lower 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* Pasadena - 5681 Fairmont Pkwy, Suite B, Pasadena, TX 77505 Pearland - 11302 Broadway St, #104 Pearland, TX 77584 Gulfgate - 995 Gulfgate Center Mall, Houston, TX 77087 Baytown - 6502 Garth Rd, Suite 100, Baytown, TX 77521 Humble - 20135 Hwy 59 North, Suite A, Humble, TX 77338 North Heights - 2401 North Shepherd Dr, Suite 160, Houston, TX 77008 Hwy 6 - 3402 S Texas 6, #C, Houston, TX 77082 Patient Shipping Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Confirmation of Upper & Lower Impressions or Models*Both the upper and lower 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
