Pre-submission worksheet

Pre-submission worksheet

Do not submit this form to Elle Jordan Lab Star Portal. This optional worksheet can be used to prepare for submitting a case at Elle Jordan Lab Star Portal.

Basic Information


Date:
Doctor's Name:
Patient's Name:
Patient's Gender: MaleFemale
Patient's Date of Birth:
Duration: RecommendLimit steps to:

Existing Condition

Chief complaint:

Upper Midline centeredshifted rightshifted left

shift in mm

Lower Midline centeredshifted rightshifted left

shift in mm


Canine Midline
right: class
left: class


Molar Midline
right: class
left: class


Instructions

Treat arches upperlower
Upper midline maintainimproveidealize
Lower midline maintainimproveidealize
Overjet maintainimproveidealize
Overbite maintainimproveidealize
Arch form maintainimproveidealize
Canine relationship maintainimproveidealize
Molar relationship maintainimproveidealize
Posterior crossbite maintainimproveidealize

IPR yesnoonly if needed
Engagers yesnoonly if needed
Procline yesnoonly if needed
Expand yesnoonly if needed
Distalize yesnoonly if needed

Other intructions:


Do not move these teeth (bridges, ankylosed teeth, etc.)

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Avoid engagers on these teeth (facial restorations, etc.)

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I will extract these teeth before the treatment

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Leave these spaces open

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