B-Align PRESCRIPTION
PATIENT Full name
Email:
Age :
Date: Chief complaint
B-Align PACKAGE : Tiny xxx xxx xxx
TREATED ARCHES Upper Only Lower Only Both
3. TOOTH MOVEMENT RESTRICTION
4. DO NOT PLACE ATTACHMENTS ON THESE TEETH
5. ANTERIOR - POSTERIOR (A-P) RELATIONSHIP : Maintain Improve canine relationship only Improve canine & molar relationship up to 4 mm Correction to Class I (canine & molar) Distalisation (up to 2 mm, without elastics)
Central incisors Lateral incisors Note: Placement of Bite Ramps will take the place of the upper anterior
Upper
Lower
11. CROWDING RESOLUTION
Procline: Primarily As needed None Expand: Primarily As needed None IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None Lower Procline: Primarily As needed None Expand: Primarily As needed None IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None 12. COMPLIANCE INDICATOR Yes (fee applies) No Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages). ADDITIONAL INSTRUCTION note: image zip file 3D scan file Other file
Expand: Primarily As needed None IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None Lower Procline: Primarily As needed None Expand: Primarily As needed None IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None 12. COMPLIANCE INDICATOR Yes (fee applies) No Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages). ADDITIONAL INSTRUCTION note: image zip file 3D scan file Other file
IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None Lower Procline: Primarily As needed None Expand: Primarily As needed None IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None 12. COMPLIANCE INDICATOR Yes (fee applies) No Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages). ADDITIONAL INSTRUCTION note: image zip file 3D scan file Other file
IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None Lower Procline: Primarily As needed None Expand: Primarily As needed None IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None 12. COMPLIANCE INDICATOR Yes (fee applies) No Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages). ADDITIONAL INSTRUCTION note: image zip file 3D scan file Other file
IPR Posterior Left: Primarily As needed None Lower Procline: Primarily As needed None Expand: Primarily As needed None IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None 12. COMPLIANCE INDICATOR Yes (fee applies) No Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages). ADDITIONAL INSTRUCTION note: image zip file 3D scan file Other file
Procline: Primarily As needed None Expand: Primarily As needed None IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None 12. COMPLIANCE INDICATOR Yes (fee applies) No Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages). ADDITIONAL INSTRUCTION note: image zip file 3D scan file Other file
Expand: Primarily As needed None IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None 12. COMPLIANCE INDICATOR Yes (fee applies) No Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages). ADDITIONAL INSTRUCTION note: image zip file 3D scan file Other file
IPR Anterior: Primarily As needed None IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None 12. COMPLIANCE INDICATOR Yes (fee applies) No Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages). ADDITIONAL INSTRUCTION note: image zip file 3D scan file Other file
IPR Posterior Right: Primarily As needed None IPR Posterior Left: Primarily As needed None 12. COMPLIANCE INDICATOR Yes (fee applies) No Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages). ADDITIONAL INSTRUCTION note: image zip file 3D scan file Other file
IPR Posterior Left: Primarily As needed None 12. COMPLIANCE INDICATOR Yes (fee applies) No Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages). ADDITIONAL INSTRUCTION
12. COMPLIANCE INDICATOR
Free additional aligners within Treatment Expiration Date (1 for Express Package, 2 for Lite Package and unnlimited for Moderate and Comprehensive Packages).
ADDITIONAL INSTRUCTION
