TPO

3Dlab@tportho.com

800-348-8856

Setup & Positioner Prescription Rx

Please use Google Chrome or Firefox as other browsers can yield unpredictable results

First Case with TP?

Yes

Account Number

Doctor Name

Phone Number

Patient Name

Shipping

Ground

Second Day

Overnight

First Class

Review & Approve Set-up Online?

Yes

No

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

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

Sending Files

Models Submitted

Recent - appliances off

Original

Appliances On

Completed set-up

Centric Occlusion By

Backs parallel

Wax bite

Lines on buccal surfaces of molars

Appliances

Positioner

Mini-Positioner

Refine™

Material

Black Rubber

White Rubber

Soft crystal-Flex®

Medium crystal-Flex®

Positioner color

Seating Springs

No

Yes - Draw arrows to indicate location

Seating Springs Location

Select a brush color: Font Color

Select a stroke width:

Hinge Axis

Use average

Headplate sent under separate cover

Tracing enclosed

Socket Liners or Bridges

Socket Liners

Socket Bridges

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

Date_Required

Date Picker

email

Address

City

State

Zip

Date Shipped to TPO

Date Picker