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Application for the production of fixed orthopedic products №

* NIP

* Patient's first and last name

Clinic name

Patient's age

* Doctor's first and last name

Date of the first fitting

* Contact email

Date of the second fitting

* Contact phone number

* Expected order receipt date

* Application completion date

* Type of application:

Fill out the form: indicate bridges, crowns, and/or implants

teeth
  • 18
  • 17
  • 16
  • 15
  • 14
  • 13
  • 12
  • 11
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
teeth
  • 48
  • 47
  • 46
  • 45
  • 44
  • 43
  • 42
  • 41
  • 31
  • 32
  • 33
  • 34
  • 35
  • 36
  • 37
  • 38
Tooth shape
Shape of gaps (pontics)
Contact points
Shape of the gingival bed
Type of fixation:
Shade guide:
scheme

Stump shade

* Tooth shade

Upload intraoral scans

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Drag files here

or click to select files

Upload a photo protocol

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or click to select files

Upload additional elements

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or click to select files

Special wishes and recommendations

* Delivery address