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About
Process
Case
Setup (Diagnostic) Request Form
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Nanoligner
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About
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Case
Setup (Diagnostic) Request Form
Contact
Nanoligner Clear Aligner Setup (Diagnostic) Request Form
Clinic Name / Patient’s Scheduled Visit Date
Patient Name/Age/Sex
Select the Treatment Arch
Both arches (Upper + Lower)
Single arch – Upper only
Single arch – Lower only
Chief Complaint (C.C.) (Example: “I want to close the spaces between my front teeth.”)
Teeth where attachments should NOT be placed(Example: restored teeth, implant crowns, etc. Please specify tooth numbers.)
Is there an extraction plan?
Yes(Please list the tooth/teeth to be extracted in the “Other Notes” section below using tooth numbering.)
No
Others:
Additional treatment requests (other than the C.C.)/(Example: “Set up with maximum IPR,” “Prefer to attempt arch expansion first,” etc.)
Other Notes / Special Considerations / (Examples: teeth with restorative/endodontic treatment, sensitive teeth, periodontal concerns, etc. Please specify tooth numbers.)
Aligner Sheet Selection
1. Soft/Hard combination (Default; most recommended)
2. Soft sheet only (Recommended for poor crown-to-root ratio or teeth with mobility)
3. 0.030/0.040 Hard sheet (Used for posterior expansion, etc.)
4. Graphy sheet (Allergic reactions may occur)
Number of aligners to manufacture and ship at one time
8 per arch (Default)
Other: ______ per arch
Others:
If the patient will be unable to visit for more than 3 months (e.g., study abroad), you may request a larger shipment or a temporary retainer.
Scan File (STL) – Upper Arch
Upload file
file upload button
()
file remove button
Scan File (STL) – Lower Arch
Upload file
file upload button
()
file remove button
Panoramic X-ray (Panorama)
Upload file
file upload button
()
file remove button
Lateral Cephalometric X-ray (if available)
Upload file
file upload button
()
file remove button
Frontal Cephalometric X-ray (if available)
Upload file
file upload button
()
file remove button
Intraoral Photos – Frontal
Upload file
file upload button
()
file remove button
Intraoral Photos – Right Buccal
Upload file
file upload button
()
file remove button
Intraoral Photos – Left Buccal
Upload file
file upload button
()
file remove button
Intraoral Photos – Upper Occlusal
Upload file
file upload button
()
file remove button
Intraoral Photos – Lower Occlusal
Upload file
file upload button
()
file remove button
Extraoral Photos – Frontal
Upload file
file upload button
()
file remove button
Extraoral Photos – Frontal Smile
Upload file
file upload button
()
file remove button
Extraoral Photos – Profile (90°)
Upload file
file upload button
()
file remove button
Additional Requests / Notes
Country / Clinic Address
Email Adress
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