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Prescription (Pre-Treatment)

Clinic Details

Please ensure you follow the prescribed guidelines to enter patient details and submit this record immediately after the appointment.

Patient Details

Upload Prescription

Please mention the required treatment and the procedure cost in your letterhead/prescription. Add your signature and the clinic seal and upload the prescription here.

Clinical Notes

Upload Pre-Treatment Photos

Add only JPG or PNG image. Size Limit: 2MB

Upper Occlusal

Lower Occlusal

Problem Area

Additional Photo

Pre-Op X-ray

Please share additional images, if any, via e-mail or WhatsApp