Lab Submission Portal
Patient Information
Patient Name
*
Patient Type
*
Internal patient
Smile White Referral
Smile White Patient Number
*
Product
*
Retainer
Whitening Tray
Mouthguard
Arch type
*
Lower Arch
Upper Arch
Dual Arch
Delivery
*
Deliver to patient?
Delivery address
*
Delivery postcode
*
Delivery City
*
Upload
*
Please attach any photos or scans
*
Upload 2 (Optional)
Upload a second file if needed
Dentist Information
Dentist Name
Practice Name
*
Practice address
*
Practice postcode
*
Please use this section to leave any notes or comments regarding the case
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