Rx – Pre-Submission Form DOCTORS PORTAL LOGIN Rx - Pre-Submission Form General Information Doctor’s Name: Doctor’s Email: Patient’s ID: Gender: MaleFemale Age (optional): Present Clinical Condition Patient’s Chief Complaint: Canine Class Relationship: Right Left Molar Class Relationship: Right Left Upper Midline: CenteredShifted RightShifted Left mm mm Lower Midline: CenteredShifted RightShifted Left mm mm Instructions (Default options are highlighted) Treat Arches: UpperLower Upper Midline: MaintainImproveIdealize Lower Midline: MaintainImproveIdealize Overjet: MaintainImproveIdealize Overbite: MaintainImproveIdealize Canine Relationship: MaintainImproveIdealize Molar Relationship: MaintainImproveIdealize Posterior Crossbite: MaintainImproveIdealize IPR: YesNoIf Needed Engagers: YesNoIf Needed Expand: YesNoIf Needed Distalize: YesNoIf Needed Special Instructions: Dr. Signature : Date: License No: Personal Information Your name: Your Email: Upload File(optional): Enclosed Records (Please email photos and records to: Here with Patient and Doctor names) Enclosed Records: Digital ScansPVS ImpressionsBite Registration X-rays: PanoFMS Photos: Max & Mand Occlusal ViewsPortrait - At ResRight & Left Vesitbular ViewsPortrait - SmilingAnterior - In OcclusionProfile - Lip Position & Profile Do not move these teeth (bridges, implants, ankylosed teeth) R 123456783231302928272625 L 9101112131415162423222120191817 Avoid engagers on these teeth: R 123456783231302928272625 L 9101112131415162423222120191817 I will extract these teeth before treatment: R 123456783231302928272625 L 9101112131415162423222120191817 Leave these spaces open: Leave these spaces open 1234567891011121314151632313029282726252423222120191817 Δ
