Mouthguard 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 Mouthguard Quantity

Lower Mouthguard Quantity

Create Reserviour For Braces or Attachments

Not Applicable

No

yes

Remove Braces Or Attachments

Not Applicable

No

yes

Upper Mouthguard Thickness

3mm – Level 1 Limited Contact Sports

4mm – Leval 2 Limited To Moderate Contact

5mm – Level 2 Moderate Contact Sports

6mm – Level 3 High Contact Sports

Lower Mouthguard Thickness

3mm – Level 1 Limited Contact Sports

4mm – Leval 2 Limited To Moderate Contact

5mm – Level 2 Moderate Contact Sports

6mm – Level 3 High Contact Sports

One Color

Two Color – Describe Any Combination Of The Above Colors

Three Color – Describe Any Combination Of The Above Colors

Describe a Custom Color Pattern

Sparkle Options – All 4mm – No logos

Tie Dye Options – All 4mm – No Logos

Helmet Strap –

No

Yes – Logo cannot be placed right off-center, front center, or left off-center

Logo Location

Right Buccal

Right Off-Center

Logo Location

Front Center

Lingual Center

Logo Location

Left Buccal

Left Off-Center

Logo Location

Right Lingual

Logo Location

Left Lingual

Right Buccal

Maximum file size: 516MB

Right Off-Center

Maximum file size: 516MB

Front Center

Maximum file size: 516MB

Lingual Center

Maximum file size: 516MB

Left Buccal

Maximum file size: 516MB

Left Off-Center

Maximum file size: 516MB

Left Lingual

Maximum file size: 516MB

Right Lingual

Maximum file size: 516MB

Lingual Cener

Maximum file size: 516MB

Special 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