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Business Email address
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Case ID
*
An identifier to help you reference the case when you receive it. If you must use the patient's name, please refrain from using the full name. Abbreviate the first or last name. If you would like attach specific dentist name this would be the place to do so. Example: C.Klara04181990 - DrJohnDoe
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Quantity
*
Please select quantity
1 - $ 68.00
2 - $ 136.00
3 - $ 204.00
4 - $ 272.00
5 - $ 340.00
6 - $ 408.00
7 - $ 476.00
8 - $ 544.00
Each tooth or abutment is a unit. For example bridge 13-15 is 3 units.
Quantity Discounted Prices
*
Please select quantity
1 - $ 1.00
2 - $ 2.00
3 - $ 3.00
4 - $ 4.00
5 - $ 5.00
6 - $ 6.00
7 - $ 7.00
Tooth number(s)
*
Shade
*
Please select the shade
A1
A2
A3
A3.5
A4
B1
B2
B3
B4
C1
C2
C3
C4
D2
D3
D4
Special Request
Special instructions
Dicount Code
Payment Options
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Please select a payment option
Pay with saved card
Pay online
Free - Redo case
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Stripe Credit Card
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Card
Name on Card
Total
$ 0.00
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