RX FormDentist Portal This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.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?We would love to chat with you. How can we get in touch?Preferred Method of Contact(Required)EmailPhoneYour Email Address(Required) Your Phone(Required)Case DetailsTemporary Fabrication Instructions(Required)Digital Designed & PrintedTraditional ConversionFinal Prosthesis(Required)Bar HybridZirconiaCoping BridgeSelect Type(Required)UpperLowerDouble ArchSurgical Guide Needed?(Required) Yes No Smart X Conversion Kit Needed?(Required) Yes No Are There Extractions?(Required) Yes No Is Patient Being Sedated?(Required) Yes No Add a Nightguard?(Required) Yes No Implant Platform(Required)Nobel BioCareStraumannZimVieOtherCase 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).
