Aligner Prescription – Straight2You Orthodontic Laboratory

Patient’s Name

Patient's Name

First Name

Last Name

Date of Birth

Is this a new sase/start or a refinement

Start/New Case

Refinement

Upper Model File

Required upload size: 1MB – 1073.74MB

Lower Model File

Required upload size: 1MB – 1000MB

Panoramic Radiograph

Maximum file size: 516MB

Composite Photos

Maximum file size: 516MB

Make Upper Aligners

Yes

No

Make Lower Aligners

Yes

No

Clinical Conditions To Address

General Clinical Conditions To Address

Upper Teeth To Be Moved

None

UR3 to UL3 (Canine to Canine)

UR5 to UL5 (2nd Premolar to 2nd Premolar)

All Upper Teeth

Lower Teeth To Be Moved

None

LR3 to LL3 (Canine to Canine)

LR5 to LL5 (2nd Premolar to 2nd Premolar

All Lower Teeth

Describe Special Upper Tooth Movements- if detail needed

Describe Special Lower Tooth Movements-if detail needed

Do Not Move – ie implants

Do Not Move – ie Implant

Extraction Planned

Extraction Movements. ie close space, maintain space, create ideal space for restoration

Is Maxillary IPR indicated

No

Yes

If Needed

Is Mandibular IPR indicated

No

Yes

If Needed

Maxillary Bite Ramps

Cuts For Elastics

No Elastics

Class II Elastics with elastic cut out on U3s and U shaped button cut outs on L6s for bonded buttons

Class II Elastics with U shaped button cut out on U3s and L6s for bonded buttons

Class II Elastics with elastic cut outs on U3s and L6s

Class III Elastics with elastic cut out on the L3s and U shaped button cut outs on U6s for bonded buttons

Class III Elastics with U shaped Button Cut Outs on L3s and U6s for bonded buttons

Class III Elastics with U shaped button cut outs on L3s and U6s for bond buttons

Anterior Box Elastics – U spaed button cut outs for bonded buttons. Specify location in box below

Posterior Box Elastics – U shaped button cut outs for bonded buttons. Specify location in box below

Special Elastic Cut Outs and/or U Shaped Button Cut Outs – if needed

Upper Aligner Material

Allow S2Y To Decide

Zendura Flx .03″ (0.76mm)

Comfort Track .03″ (0.76mm)

Essix Ace .03″ (0.75mm)

Zendura Viva .035″ (0.89mm)

Glacier .03mm (0.76mm)

Lower Aligner Material

Allow S2Y To Decide

Zendura Flx .03″ (0.76mm)

Comfort Track .03″ (0.76mm)

Essix Ace .03″ (0.75mm)

Zendura Viva 0.35″ (0.89mm)

Glacier .03mm (0.76mm)

Custom Aligner Material Choice

Upper Aligner Trim

Scalloped

Straight At Zenith Of Free Gingival Margin

Straigth 1-2mm Apical of Free Gingival Margin

Lower Aligner Trim

Scalloped

Straight At Zenith Of Free Gingival Margin

Straight 1-2mm Apical Of Free Gingival Margin

Custom Aligner Trim

Upper Posterior Trim

Trim As Needed

Wrap/Cover Distal Surface

Cover Occlusal Surface

To Central/Developmental Groove

Distal of Second Most Posterior Tooth

Lower Posterior Trim

Trim As Needed

Wrap/Cover Distal Surface

Cover Occlusal Surface

To Central/Posterior Groove

Distal of Second Most Posterior Tooth

Custom Posterior Trim

Use Upper Attachments – Additional attachments if refinement

Yes

No

Use Lower Attachments – Additional attachments if refinement

Yes

No

Pontic location

Pontic Location

If you would like us to fill the pontic – describe shade.

Upper Bar Locations

Lower Bar Locations

Describe Custom Bar Location – if more detail is needed

Doctor’s Name

Doctor's Name

First Name

Last Name

Doctor’s Email

Doctor’s Phone

Doctor’s License Number

Ship To Doctor

Yes

No

Default is Yes

Ship To Patient

Yes

No

Default is No

Automatic PDF Download after Submit?

yes

no

(Default = No)

Flatten PDF File Setting?

yes

no

(Default Value in Field Map Layout )

Address

City

State/Province

Zip/Postal

Country

S2Y Aligner Prescription