Submission worksheet

The Ultimate Smile Makeover Experience! Where Custom Smiles are Crafted™

Submission worksheet

Do not submit this form to Elle Jordan. This worksheet should be used to prepare for sobmitting a case at ElleJordan Studios

Basic Information

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

Existing Condition

Chief complaint:

Upper Midline centeredshifted rightshifted left
shift in mm
Lower Midline centeredshifted rightshifted left
shift in mm
Which midline is centered
best in the face?

UpperLower

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
IPR yesnoonly if needed
Engagers yesnoonly if needed

Procline yesnoonly if needed
Expand yesnoonly if needed
Distalize yesnoonly if needed
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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Other intructions:

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