Section 1 of 1 in this document
Setup & Positioner Prescription Rx
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First Case with TP?
Yes
Account Number
Doctor Name
*
Phone Number
Patient Name
*
Shipping
Ground
Second Day
Overnight
First Class
Regular Setup
Diagnostic; no appliance
Compromised
Partial set-up
Full set-up
Sculpturing Instructions
Remove all attachments
Retain first molar bands
Retain lower 3-3 retainer
Remove lower 3-3 retainer
Reset
All Teeth
Teeth Indicated
Reset Upper Right
8
7
6
5
4
3
2
1
Reset Upper Left
1
2
3
4
5
6
7
8
Reset Lower Right
8
7
6
5
4
3
2
1
Reset Lower Left
1
2
3
4
5
6
7
8
Review & Approve Set-up Online?
Yes
No
Overbite
Ideal (1-2 mm)
Overbite - Other Amt
Overjet
Ideal (0 mm)
Overjet - Other Amt
Anterior Root Torque - Upper
Same
2º Palatally
2º Labially
Anterior Root Torque - Lower
Same
2º Lingually
2º Labially
Spaces
Close all
Compromise
Leave space
Leave space between
In Case of Discrepancy
Good Cl. I molar relation
Good Cl. I cuspid relation
Space between cuspid/bicuspid
Space between lateral/cuspid
Occlusal Plan
Flat
Curve of spee
Arch Form
Ideal
Approximately the same
Straight Arch
Arch Width - Upper
Same
Expand __ mm
Constrict __ mm
Arch Width - Lower
Same
Expand __ mm
Constrict __ mm
Block Out Lingual Retainer - Upper
1-1
2-2
3-3
4-4
Block Out Lingual Retainer - Lower
1-1
2-2
3-3
4-4
Block Out Pontics Where Necessary
Yes
Block Upper Right
8
7
6
5
4
3
2
1
Block Upper Left
1
2
3
4
5
6
7
8
Block Lower Right
8
7
6
5
4
3
2
1
Block Lower Left
1
2
3
4
5
6
7
8
Appliances
Positioner
Mini-Positioner
Refine™
Seating Springs
No
Yes
Seating Spring Instruction
Place one check mark for each seating spring requested, and a seating spring will be placed mesial to each tooth selected.
Seating Springs Upper Right
7
6
5
4
Seating Springs Upper Left
4
5
6
7
Seating Springs Lower Right
7
6
5
4
Seating Springs Lower Left
4
5
6
7
Hinge Axis
Use average
Headplate sent under separate cover
Tracing enclosed
Socket Liners
No
Yes on Teeth Indicated
Socket Upper Right
2
1
Socket Upper Left
1
2
Socket Lower Right
2
1
Socket Lower Left
1
2
Appliance Height
Normal
Low
High
Appliance Thickness
Normal
Thick
Thin
Molded Airways
Yes
No
End Appliance Distal To
First Molars
Second Molars
Other
End Appliance Distal to Other
Special Instructions
Sending Files
Choose One
iTero
CS Connect
3M
Shipment
Other
Date_Required
*
email
*
Address
*
City
*
State
*
Zip
*
Date Shipped to TPO
Material
Soft crystal-Flex®
Medium crystal-Flex®
disregard this