Upper midline ○ centered ○ shifted right mm ○ shifted left mm Lower midline ○ centered ○ shifted right mm ○ shifted left mm Canine relationship right: class left: class Molar relationship right: class left: class Chief complaint: INSTRUCTIONS Please submit this form with your case or email it to [email protected] Default options are highlighted in green Straight28™ Clear Aligner Prescription BA S I C I N F O R M AT I O N Treat arches □ upper □ lower Upper midline ○ maintain ○ improve ○ idealize Lower midline ○ maintain ○ improve ○ idealize Overjet ○ maintain ○ improve ○ idealize Overbite ○ maintain ○ improve ○ idealize Arch form ○ maintain ○ improve ○ idealize Canine relationship ○ maintain ○ improve ○ idealize Molar relationship ○ maintain ○ improve ○ idealize Posterior crossbite ○ maintain ○ improve ○ idealize ○ only if needed ○ only if needed ○ only if needed ○ only if needed IPR ○ yes ○ no Buttons ○ yes ○ no Procline ○ yes ○ no Expand ○ yes ○ no Distalize ○ yes ○ no ○ only if needed Other instructions: Do not move these teeth (bridges, ankylosed teeth, etc.) R L 1 2 3 4 5 6 7 8 32 16 17 31 15 18 30 14 19 29 13 20 28 12 21 27 11 22 26 10 23 25 9 24 Avoid buttons on these teeth (facial restorations, etc.) R L 1 2 3 4 5 6 7 8 32 16 17 31 15 18 30 14 19 29 13 20 28 12 21 27 11 22 26 10 23 25 9 24 I will extract these teeth before treatment R L 1 2 3 4 5 6 7 8 32 16 17 31 15 18 30 14 19 29 13 20 28 12 21 27 11 22 26 10 23 25 9 24 Leave these spaces open R L 1 2 3 4 5 6 7 8 32 16 17 31 15 18 30 14 19 29 13 20 28 12 21 27 11 22 26 10 23 25 9 24 / / Date Doctor’s name Patient’s name Patient’s gender ○ Male ○ Female Patient’s date of birth Requested Return Date ____________ (Please allow at least 2 weeks in lab) INITIAL EXAMINATION DATA