Digital Wax Up RX Order Form

Please complete the entire form below. All fields indicated by * are required. 

Digital wax up cases include case design, 3D printed wax up model, putty matrix for temporary fabrication, and suck-down appliance for prep guide.


Failure to submit necessary records will result in delays to your case.

Patient Identification

Billing Doctor Details

The case will be entirely billed to this doctor.

Treatment Plan Information