straight28™ clear aligner prescription
TRANSCRIPT
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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Default options are highlighted in green
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