Pre-Surgery Data Set Rx (1 of 2)

Restorative Doctor Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Patient Name *

First Name

Last Name

Gender *

Male

Female

If you are doing your own surgery write in the box bellow: "ME" *

Specialist's name

First Name

Last Name

Surgery Date

As previously mentioned, we may not be able to meet your surgery date based on your requirements.

MM

DD

YYYY

Time of Surgery *

The cut-off time to receive files is noon PST. Any files received after 12PM PST will delay the case an extra day. Any rush cases will accrue an extra charge of $500 plus the cost of shipping. Schedule: local California cases: 24hrs turn-around time if files are received by noon PST the day of surgery. Out of state cases: 48 to 72 Hrs based on location if files are received by noon PST the day of surgery.

Hour

Minute

Second

AM PM

Teeth Shape *

Copy Existing Shape of Teeth

Improve Shape of Teeth

Would you like to include a Night Guard? (Highly Recommended) *

Yes

No

Select how you would like to have the case approved: *

No need to review the case, complete case.

Please email 3D viewer for case approval.

I would like to approve my case with an online review session.

Temporary Restoration *

Important: make sure to choose correct location. Allure Dental Studio will not be responsible for incorrect inputed address.

Send the temporary to SPECIALIST office.

Send the temporary to RESTORATIVE office.