"*" indicates required fields

Has This Patient Finished Wearing All the Aligners for this Case?*

Yes

No

Instead of a REFINEMENT (Post-Treatment), please submit a REVISION (Mid-Treatment) request using the REVISION submission form found in the patient's portal, or via the navigation bar under "Case Manager" at the top of any page.

Doctor Name*

First Last

Patient Name*

First Last

Dental Notation Preference*

Universal/American

Palmer

Arches*

Upper & Lower

Upper Only

Lower Only

IPR - Interproximal Reduction or Stripping of Enamel*

Yes

Only if Recommended

No

Bite Ramps*

Yes

Only if Recommended

No

Attachment Preference*

Yes

Only if Recommended

No

Enter Additional Instructions

Would You Like to Use Pontics for Any Missing Teeth?*

Additional cost of only $1.95 per pontic/per aligner.

Yes

No

Note UPPER MISSING TEETH with an X

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Note LOWER MISSING TEETH with an X

31

30

29

28

27

26

25

24

23

22

21

20

19

18

Note UPPER MISSING TEETH with an X

UR7

UR6

UR5

UR4

UR3

UR2

UR1

UL1

UL2

UL3

UL4

UL5

UL6

UL7

Note LOWER MISSING TEETH with an X

LR7

LR6

LR5

LR4

LR3

LR2

LR1

LL1

LL2

LL3

LL4

LL5

LL6

LL7

Pontic Shade*

Light

Medium

Dark

New Dental Work*

Yes

No

Note Type of Dental Work on Involved UPPER TEETH (I = Implant, V = Veneer, C = Crown, B = Bridgework, P = Partial)

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Note Type of Dental Work on Involved LOWER TEETH (I = Implant, V = Veneer, C = Crown, B = Bridgework, P = Partial)

31

30

29

28

27

26

25

24

23

22

21

20

19

18

Note Type of Dental Work on Involved UPPER TEETH (I = Implant, V = Veneer, C = Crown, B = Bridgework, P = Partial)

UR7

UR6

UR5

UR4

UR3

UR2

UR1

UL1

UL2

UL3

UL4

UL5

UL6

UL7

Note Type of Dental Work on Involved LOWER TEETH (I = Implant, V = Veneer, C = Crown, B = Bridgework, P = Partial)

LR7

LR6

LR5

LR4

LR3

LR2

LR1

LL1

LL2

LL3

LL4

LL5

LL6

LL7

Panoramic X-Ray

Recommended

Drop files here or Select files

Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 1 GB.

Cephalometric X-Ray

Recommended

Drop files here or Select files

Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 1 GB.

Profile Pictures

Recommended - front relaxed, front smiling, right side profile relaxed

Drop files here or Select files

Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 1 GB.

Intraoral Pictures

Recommended - frontal, right buccal, left buccal, upper arch, lower arch

Drop files here or Select files

Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 1 GB.

Model Type*

NOTE: Both an upper & lower intraoral scan, PVS impression, or stone model are required for all case submissions

Intraoral Scans (STL Files)

PVS Impressions

Stone Models

Scanner Used*

Trios

iTero

Omnicam

Primescan

Carestream

Heron

Medit

3M

Planmeca

Other

Upload Intraoral Scans

Drop files here or Select files

Accepted file types: stl, dcm, stl, dcm, Max. file size: 1 GB.

Need a Prepaid Shipping Label for Impressions/Models?*

Yes

No

Email Address for Sending Shipping Label*

This field is hidden when viewing the form

Production Priority*

Normal production time is approximately 7-10 business days from the time the SmileDesign is accepted.

Normal

RUSH ($250 Additional Fee)

This field is hidden when viewing the form

Requested RUSH Delivery Date for Aligners

MMMM123456789101112

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YYYYYYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Ship To:*

Office Address

Patient Address

Office Shipping Address*

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Patient Shipping Address*

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Confirmation of Upper & Lower Scans, Impressions, or Models*

Both the U & L scans, models, or impressions have been taken and will be included in the case submission

Yes

Confirmation of Informed Consent & Agreement*

The patient has signed or will sign the Trez PRO Informed Consent & Agreement found in the Doctor Info section of this website

Yes

Consent to Terms of Use & Service and Privacy Policy*

I accept and agree to the Trez PRO Terms of Use, Terms of Service, and Privacy Policy found in the About Us section of this website

Yes