Rx for Clear Aligner DesignPlease complete the following form for a Clear Aligner case. Doctor's Name * First Name Last Name Patient's Name * First Name Last Name Patient Information * Gender: Male Female Age: * Medications that may affect treatment: Relevant Dental History Periodontal Status * Areas of thin gingival attachment? Yes No If yes, provide tooth number(s) Loss of attachment? Yes No If yes, provide tooth number(s) Do you wish to minimize movement in that area? Yes No Treatment Specification * Do you want to align the treatment from: 3-3 (anterior only) 5-5 (2nd premolar to 2nd premolar) 7-7 (full-arch treatment, add'l fee will apply) Treatment * (see below for details) Upper Esthetic Treatment Lower Esthetic Treatment Allow IPR * Yes No Allow Attachments * Yes No Midlines (mark only if needed) Do you want to? Improve Maintain Move Upper Left Right Move Lower Left Right Anterior Posterior Relation * Maintain Upper Lower Improve Canine relationship Left Right Improve Molar Relationship Left Right Anterior Posterior Relation * How do you want to level the anterior teeth? Incisal edges Gingival margins Overjet & Overbite * Overjet Maintain Improve * Overbite Maintain Improve Tooth Size Discrepancy IPR in Opposite Arch Leave Spaces Open Distal to Laterals Distal to Canines Posterior Cross-bite Maintain Correct Premolars Correct Molars Additional Comments Thank you!
