Digital Services Prescription – Straight2You Orthodontic Laboratory

Patient’s Name

Patient's Name

First Name

Last Name

Date of Birth

Upper Model File

Required upload size: 1MB – 1073.74MB

Lower Model File

Required upload size: 1MB – 1000MB

Upper Model Digital Services

Yes

No

Lower Model Digital Services

Yes

No

Type Of Digital Service

Digtial File Only

3D Printed Model Only

Digital File and 3D Printed Model

Remove Braces Or Attachments

Not Applicable

No

yes

Special Note About Removal Of Braces Or Attachments

Blockout Model for undercuts

No

Yes – details described below

Yes – all S2Y to decide

Special Note About Blockout Model For Unercutsts

Molar Ditching Models

Not Applicable

No

Yes

Special Note About Molar Ditching Models

Bleaching Trays Gel Pocket

Eyelid Gel pocket

Partial Coverage Gel Pocket

Full Coverage Gel Pocket

Bleaching Trays Pressure Seal

No

Yes

Special Note About Bleaching Trays

Bonded Retainer Blockout

No

Yes

Pontic

Bar Location

Describe Custom Bar Location – if more detail is needed

Describe Minor Upper Tooth Movements

Describe Minor Lower Tooth Movements

Special Notes Or Requests

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