Imaging Order Form
Date
Dentist Name
Street Address
City
State
Country
Zip
Phone Number
E-Mail Address
Patient's Name
Provide a detailed discription of the proposed therapy.
Shade Desired
Will the remaining teeth
be bleached to match?
Yes
No
Style Guide Name and Number
Please check the boxes next to the teeth
that are to be corrected.
You may receive the completed simulation
in any of several formats.
Please choose any or all of the following:
1) before & after photos
2) 8 x 10 layout on letterhead
3) Flash Movie
4) 8 x 10 print via USPS - add $25
5) Secure webpage
Once this page is submitted, a page will appear from which you may send the patient's photo.
You may use this form to submit instructions and a photo for imaging or
you may send detailed instructions in an e-mail with photo attached.
No need to resubmit your contact details after your first case, just your name is enough.
