NuevosOrtodoncia | RealAligner clientes

USER DATA (Data collected from your user, not modifiable)

Customer Name *

Clinic*

Email *

Telephone number*

* Required information.

INFORMATION ABOUT THE CLINICAL CASE

PATIENT DATA

Patient identification

Date of birth

Gender

Woman

Man

Others

Golden Card Code

DR./DR.'S INFORMATION.

Facturación

Propia

Clínica

CIF

Dirección de facturación

Razón Social

First name and surname*

Membership number

Email*

Telephone*

Tipo de planificacion *

Planifiación Express

(Se obtendrá en máximo 24hrs laborales. Considerar que este plan de tratamiento NO contempla secuencia, el número de alineadores NO será el real, solo es un aproximado)

Planificación con secuencia

(Se obtendrá en un máximo de 72hrs laborales. Propuesta que considera las instrucciones y objetivos que indicó el Dr y/o la secuencia que nuestro equipo considera como mejor opción para un tratamiento predecible)

Treatment*

Initial treatment

Refinement

Retainer

Membership number*

Superior

Lower

Both

Right upper jaw (not moving or missing)

Mark the teeth that you do not want to move or that are missing. (It is not mandatory to mark any.)

Left upper jaw (not moving or missing)

Mark the teeth that you do not want to move or that are missing. (It is not mandatory to mark any.)

Right lower jaw (not moving or missing)

Mark the teeth that you do not want to move or that are missing. (It is not mandatory to mark any.)

Lower left jaw (not moving or missing)

Mark the teeth that you do not want to move or that are missing. (It is not mandatory to mark any.)

Would you like to use attachments in your planning if necessary?

Yes

Create spaces

Yes

TREATMENT OPTIONS

Class I correction

Right canine tooth

Left canine

Right molar

Left molar

Overjet correction

Maintain

Increase

Decrease

Overbite Correction

Maintain

Increase

Decrease

Midline Correction

Keep existing

Improve upper right

Improve upper left

Improve lower right

Improve lower left

CROWDING

Upper arch

Maintain arch shape (may require IPR)

Previous IPR (from canine to canine)

Posterior IPR (molars only)

Adjust upper arch to lower arch

Lower arch

Maintain arch shape (may require IPR)

Previous IPR (from canine to canine)

Posterior IPR (molars only)

Adjust lower arch to upper arch

Clinical Instructions/Treatment Objectives *

Explain any details to be taken into account regarding the marked parts.

Reason for consultation *

Write any clarifications about space management.

Línea de corte

Línea de corte Recto

Línea de corte Festoneado

Línea de corte mixta

(indicar mms de altura y tipo de corte por segmento)

ATTACHED FILES

File names without dots or special characters. Maximum file size of 64MB, otherwise an error will occur. The connection may be interrupted if the file is too large and the connection is not stable or sufficient. If you wish to upload a larger file, please contact us so that we can transfer the file for you.

Shipping buckets *

Yes

STL files