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Clear Aligner Prescription Form

Prescribing Doctor Name:

Patient Name:

Treatment required:

Upper and Lower Upper Lower

Patient's main concern:

Treatment Goals:

Restorative Tx Plan:

Teeth to avoid moving (Upper and Lower Arch):

Teeth to avoid placing ForceDrivers (Upper and Lower Arch):

How would you like to deal with spaces?

Close them all Leave specific spaces for restorations Show me ideal result

How would you like to deal with crowding?

Anterior Alignment Preference:

Alignment to Gingival margins Alignment to Incisal edges Upper centrals longer than laterals Upper centrals and laterals at same level

Proclination Expansion IPR Show me ideal solution

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Email

Email: accounts@whitebox-dental.com

Head Office: 0141 459 0424

Digital Team: 07460 537 988

Oralcare Direct Limited T/A Whitebox Dental

44 Speirs Wharf

Glasgow

G4 9TH