Phoenix Denture Appointment Link Preferred Name Next Client Appt Date -Patient Birthdate -Provider Follow-Up -Denture Recommended Stage -Phone -Full Name -Policy Number -Insurance Company Click Here to Accept this Signature (SUB-OPTIMAL) Click Here to Accept this Signature Denture Appointment Please Indicate Below the Location of this Appoint (client building includes Sr Apartments, care centers shelters or any other building outside of a residential home) Is this appointment held in a "Client" building or a patient's home? "Client" Building Patient's Home Click Below Before Appt Begins & Patient is Sitting in Chair CLICK HERE WHEN PATIENT HAS ARRIVED CLICK HERE BEFORE APPT & PATIENT IS IN CHAIR Click Below When You are at Patient's Door CLICK HERE WHEN AT PATIENT'S DOOR I AM AT PATIENT'S DOOR *Has HIPAA Been Signed? YES- HIPAA SUBMITTED NO HIPAA SUBMITTED Who is Performing this Appointment? CLICK ON THE TEAM MEMBER PERFORMING DENTURE APPOINTMENT * Tom Wilson Cindy Marin Rylie Nilsson Kelsey Hansen Other What arch did you work on? INDICATE THE ARCH YOU WILL BE WORKING WITH TODAY: APPT TYPE SCAN SEATING WHAT ARCH DID YOU WORK ON * Maxillary Mandibular MAX ARCH MAX FULL MAX PARTIAL MAN ARCH MAN FULL MAN PARTIAL Indicate Appt Type Below INDICATE APPOINTMENT TYPE BELOW MAXILLARY PARTIAL ARCH * MAX PARTIAL Edentulous Scan MAX PARTIAL Reference Scan MAX PARTIAL Mono Try-in MAX PARTIAL Wax Rim Scan MAX PARTIAL DENTURE Seating MAX PARTIAL REFABRICATION MAX PARTIAL Adjustment MAXILLARY ARCH * MAXILLARY Edentulous Scan MAXILLARY Reference Scan MAXILLARY Mono Try-in MAXILLARY Wax Rim Scan MAXILLARY DENTURE Seating MAXILLARY REFABRICATION MAXILLARY Adjustment MANDIBULAR PARTIAL ARCH * MAN PARTIAL Edentulous Scan MAN PARTIAL Reference Scan MAN PARTIAL Mono Try-in MAN PARTIAL Wax Rim Scan MAN PARTIAL DENTURE Seating MAN PARTIAL REFABRICATION MAN PARTIAL Adjustment MANDIBULAR ARCH * MANDIBULAR Edentulous Scan MANDIBULAR Reference Scan MANDIBULAR Mono Try-in MANDIBULAR Wax Rim Scan MANDIBULAR DENTURE Seating MANDIBULAR REFABRICATION MANDIBULAR Adjustment Sent to Dandy? UPLOAD SCAN 1- UPLOAD SCAN TO DANDY AND PICS (WHEN RELEVENT) 2- DOWNLOAD SCAN FROM DANDY 3- CLICK ON LINK BELOW TO LOGIN Customer Web Access USERNAME- 20115 PASSWORD- Tru2Cor! 4- ON LEFT HANDSIDE OF SCREEN- CLICK CASES 5- CLICK ON SUBMIT CASE 6- FILL OUT FORM 7- SUBMIT 8- CLICK ON CASES AGAIN 9- CLICK ON VIEW CASES AND TYPE CASE # BELOW INDICATE BELOW WHEN SCAN HAS BEEN SENT TO PANAM, EST DELIVERY DATE & CASE # DANDY SENT * Scan Sent Scan on Hold No Scan Taken DENTURE DELIVERY DETAILS Est Delivery Date * WAX RIM- 1 WEEK PANAM DESIGN ONLY- 1 WEEK PANAM FINAL- 2 WEEKS SPRINTRAY- 1 WEEK PARTIALS- 2 WEEKS CASE # * WHERE WAS SCAN SENT? * PANAM DESIGN & ORDER FULFILLMENT PANAM DESIGN ONLY SPRINTRAY OtherOther INITIAL SCAN Do you anticipate issues with this denture fitting reasonably well? Do you anticipate issues with this denture fitting reasonably well? * No expected issues for reasonable fit Anticipated issue with future denture fit Indicate your concern below: Minimal Bone Platal Tori Uneven Gumline Existing Root Tip OtherOther DENTURE FIT ACKNOWLEDGMENT AND WAIVER I understand that my dental provider has informed me of certain oral conditions and/or limitations that may prevent me from achieving an optimal fit with my new dentures. These conditions may include, but are not limited to: Bone loss or irregular bone structure Gum tissue changes or scarring Oral anatomy that limits retention or stability Medical conditions that may affect healing or comfort I acknowledge that my provider has explained these issues to me and that I understand the limitations they may place on the fit, function, and comfort of my dentures. I further acknowledge that: My provider will make only a minimal number of adjustments to my dentures after delivery. Additional adjustments beyond those provided may require new treatment, additional costs, or referral to another provider. No guarantee has been made regarding the comfort, fit, or function of these dentures. By signing this form, I confirm that I understand and accept these limitations, and I agree to proceed with treatment under these conditions. I understand that there is significant chance of sub-optimal fit of my denture: (Type Signature Only) * signature keyboard Clear Today's Date * Click Here to Accept this Signature * Click Here to Accept this Signature CLICK BELOW ON REQUIRED ELEMENTS YOU HAVE COMPLETED INITIAL SCAN CHECK THAT INSURANCE HAS BEEN UPLOADED WAX RIM CHARISIDE APPROVAL IS REQUIRED ON WAX RIMS SCANS DANDY APPROVAL Approved WITHOUT Changes APPROVED WITH Changes I DID NOT CALL INTO CHAIRSIDE (INDICATE WHY BELOW) NAME OF CHAIRSIDE ASSISTANT WHY DID YOU NOT CALL INTO DANDY FOR CHAIRSIDE APPROVAL? Waiver of Anticipated Sub-Optimal Fit Denture Due to the issue/s indicated above, there is concern about the viability of potential dentures. We are willing to fabricate your denture, upon your request, and will do our best to obtain optimal fit. There is significate concern that your denture will not meet satisfactory conditions. We will make reasonable adjustments upon delivery of denture and follow-up but will not send denture back to re-fabrication if denture does not fit optimally. Please sign below if you would like to continue with fabricating your denture and understand that it there is a significant chance that your denture will not fit optimally. CLICK WHEN CHAIRSIDE IS COMPLETE: CLICK WHEN CHAIRSIDE IS COMPLETE CLICK BELOW ON REQUIRED ELEMENTS YOU HAVE COMPLETED WAX RIM REQUIRMENTS CHECK "INSURANCE INFO" TO ENSURE PRE-AUTH APPROVAL ADD PICTURE TO DANDY TRY IN CLICK BELOW ON REQUIRED ELEMENT/S YOU HAVE COMPLETED MONO REQUIREMENTS CHECK "INSURANCE INFO" TO ENSURE PRE-AUTH IS APPROVED SEATING/REFAB CLICK BELOW WHEN YOU HAVE VERIFIED PATIENT IS ELIGIBLE SEATING REQUIREMENTS CLICK ONCE YOU HAVE CHECK INSURANCE ELIGIBILITY STATUS Maxillary Denture Seating DENTURE SEATING (Maxillary): * CLICK HERE TO RECORD MAX SEATING RESULTSDenture Seated- No Adjustment NeededDenture Seated- Adjustment Needed at SeatingDenture Seated- NOT Optimal FitDenture Rejected by Specialist & PatientDenture Rejected by Patient ONLY REASON FOR DISCOMFORT OR UNSUCCESSFUL SEATING (Maxillary): * Falls Out Too Loose Too Tight Midline is Off Teeth Pretruding Gingival too Large Bite is Off Teeth too Big OtherOther Seating Appt Completed * CLICK HERE WHEN MAX SEATING HAS BEEN COMPLETED Mandibular Denture Seating (Mandibular): DENTURE SEATING (Mandibular) * CLICK HERE TO RECORD MAN SEATING RESULTSDenture Seated- No Adjustment NeededDenture Seated- Adjustment Needed at SeatingDenture Seated- NOT Optimal FitDenture Rejected by Specialist & PatientDenture Rejected by Patient ONLY REASON FOR DISCOMFORT OR UNSUCCESSFUL SEATING (Mandibular): * Falls Out Too Loose Too Tight Midline is Off Teeth Pretruding Gingival too Large Bite is Off Teeth too Big OtherOther Seating Appt Completed * CLICK HERE WHEN MAN SEATING HAS BEEN COMPLETED NEXT APPT * YES- Next Appt is Necessary NO- Next Appt is Necessary DO NOT CLICK "NEXT" UNTIL INDICATED Ready to Click "Next Appt " NEXT Δ