RX FormDentist Portal General InformationPhysician Name(Required) First Last Practice Name(Required)Your Address(Required) Street Address Address Line 2 City ZIP Code How Can We Reach You?Preferred Method of Contact(Required)EmailPhoneYour Email Address(Required) Your Phone(Required)Case DetailsPatient Name(Required) First Last AgeGenderMaleFemaleShadeA1A2A3A3.5B1B2B3C1C2C3D1D2D3OM1OM2OM3Other (Please include in case notes)Has Surgery Been Scheduled?(Required)If surgery has not been scheduled, please visit https://acqua-dent.com/scheduling-calendar/ to view our scheduling calendar for available dates and call Mary at our office (732) 656-3393 to confirm date of surgery. Yes No Date of Surgery(Required) MM slash DD slash YYYY Select Arch(Required) Upper Lower Double Arch Temporary Fabrication(Required) Digital Designed & Printed Traditional Conversion Request Digital Preview(Required) Yes No Were Scans or Models Sent?(Required) Scans Models Where Were Scans Sent?(Required) 3Shape Carestream iTero Medit Primescan Process Needed(Required) Bite Block Set-Up for Try-In Retry Process Conversion Denture & Clear Process 3D Printed Temp for Digital Conversion Process Prototype Process & Finish Final Prosthesis(Required) Bar Hybrid Zirconia Coping Bridge Implant Platform(Required) BioHorizons Implant Direct Neodent Nobel Norris Straumann ZimVie Smart Denture Conversion Kit Needed?(Required) Yes No Are There Extractions?(Required) Yes No Surgical Guide Needed? Yes No Is Patient Being Sedated? Yes No Add a Nightguard? Yes No Case InstructionsPlease list any other information regarding your case.Upload Photos(Required)Accepted file types: jpg, png, Max. file size: 200 MB.Please upload 3 - 10 Photos. Patient in repose (lips apart and expressionless look; Patient smiling; Patient with biggest, broadest smile).
