Skip to content

S2Y Phase 1 Retainer Prescription
Patient’s Name
Patient's Name
First Name
Last Name

Required upload size: 1MB – 1073.74MB

Required upload size: 1MB – 1000MB

Upper Phase 1 Retainer Quantity
Remove Braces Or Attachments
Upper Phase 1 Retainer Material
Upper Phase 1 Retainer Trim
Upper Bonded Phase 1 Retainer Trim
Pontic location
Pontic Location
Blockout Areas
Blockout Area
Blockout Area
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