straight28™ clear aligner prescription

Upper midline ○ centered○ shifted right mm○ shifted left mm

Lower midline ○ centered○ shifted right mm○ shifted left mm

Canine relationship right: class left: class

Molar relationship right: class left: class

Chief complaint:

I N S T R U C T I O N S

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Straight28™ Clear Aligner Prescription

B A S I C I N F O R M A T I O N

Treat arches □ upper □ lower

Upper midline ○ maintain ○ improve ○ idealizeLower midline ○ maintain ○ improve ○ idealize

Overjet ○ maintain ○ improve ○ idealizeOverbite ○ maintain ○ improve ○ idealize

Arch form ○ maintain ○ improve ○ idealizeCanine relationship ○ maintain ○ improve ○ idealize

Molar relationship ○ maintain ○ improve ○ idealizePosterior crossbite ○ maintain ○ improve ○ idealize

○ only if needed○ only if needed○ only if needed○ only if needed

IPR ○ yes ○ no Buttons ○ yes ○ no Procline ○ yes ○ no Expand ○ yes ○ no

Distalize ○ yes ○ no ○ only if needed

Other instructions:

Do not move these teeth (bridges, ankylosed teeth, etc.)

R L

1 2 3 4 5 6 7 8

32

16

1731

15

1830

14

1929

13

2028

12

2127

11

2226

10

2325

9

24

Avoid buttons on these teeth (facial restorations, etc.)

R L

1 2 3 4 5 6 7 8

32

16

1731

15

1830

14

1929

13

2028

12

2127

11

2226

10

2325

9

24

I will extract these teeth before treatment

R L

1 2 3 4 5 6 7 8

32

16

1731

15

1830

14

1929

13

2028

12

2127

11

2226

10

2325

9

24

Leave these spaces open

R L

1 2 3 4 5 6 7 8

32

16

1731

15

1830

14

1929

13

2028

12

2127

11

2226

10

2325

9

24

/ /

Date

Doctor’s name

Patient’s name

Patient’s gender ○ Male ○ Female Patient’s date of birth

Requested Return Date ____________ (Please allow at least 2 weeks in lab)

I N I T I A L E X A M I N A T I O N D A T A