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S2Y Bleaching Tray Prescription
Patient’s Name
Patient's Name
First Name
Last Name

Required upload size: 1MB – 1073.74MB

Required upload size: 1MB – 1000MB

Upper Bleaching Tray Quantity
Lower Bleaching Tray Quantity
Bleaching Tray Material
Gel Pocket Type
Pressure Seal
Doctor’s Name
Doctor's Name
First Name
Last Name
Ship To Doctor
Default is Yes
Ship To Patient
Default is No
(Default = No)
(Default Value in Field Map Layout )
Address
Address
City
State/Province
Zip/Postal
Country
Sending