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Home
About us
Appliances
3d Printing
Work Order
Standard Appliance Work Order
Smile Shapers Work Order
Blog
Contact Us
Smile Shapers Work Order
Smile Shapers Work Order
Smile Shapers RX Form
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General Information
Doctor’s Name:
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Contact Number
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Address
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Street Address
Address Line 2
City
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Armed Forces Americas
Armed Forces Europe
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State
ZIP Code
Patient’s Name
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Gender
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Male
Female
Date of Birth
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Day
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Year
2024
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1921
1920
Patient’s Chief Complaint
*
Canine Class Relationship
Right
Left
Molar Class Relationship
Right
Left
Upper Midline
Centered
Shifted Right
Shifted Right
MM
Shifted Left
Shifted Left
MM
Lower Midline
Centered
Shifted Right
Shifted Right
MM
Shifted Left
Shifted Left
MM
Instructions
Do not move these teeth
Instructions
*
New Order/Case
Refinement Case
R
1
2
3
4
5
6
7
8
25
26
27
28
29
30
31
32
L
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
If Refinement, original case #
Original length of treatment steps
Treat Arches
Upper
Lower
Avoid engagers on these teeth
Instructions #1
Upper Midline
Maintain
Improve
Idealize
Lower Midline
Lower Maintain
Lower Improve
Lower Idealize
Overjet
Overjet Maintain
Overjet Improve
Overjet Idealize
Overbite
Overbite Maintain
Overbite Improve
Overbite Idealize
Canine Relationship
Canine Maintain
Canine Improve
Canine Idealize
Molar Relationship
Molar Maintain
Molar Improve
Molar Idealize
Posterior Crossbite
Posterior Maintain
Posterior Improve
Posterior Idealize
R
1
2
3
4
5
6
7
8
25
26
27
28
29
30
31
32
L
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
I will extract these teeth before treatment
Instructions #2
IPR
Yes
No
If Needed
Engagers
Engagers Yes
Engagers No
Engagers If Needed
Procline
Procline Yes
Procline No
Procline If Needed
Expand
Expand Yes
Expand No
Expand If Needed
Distalize
Distalize Yes
Distalize No
Distalize If Needed
R
1
2
3
4
5
6
7
8
25
26
27
28
29
30
31
32
L
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Leave these spaces open
Retainers
(Smile Shapers recommends waiting for the treatment plan to be completed to fabricate the final retainers)
Leave these spaces open
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Include Final Retainer
Upper
Lower
Include 3 Pack Retainer & Extended Care Package
Upload File
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Special Instructions
Special Instructions
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