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Invisalign Refinement Form
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* Indicates required question
Email
*
Your email
Patient Name
*
Your answer
Date Scanned
MM
/
DD
/
YYYY
1. Arches to Treat
*
Both
Upper
Lower
Required
2. How would you like your treatment plan setup?
Make finishing adjustments to the current tooth positions
Continue towards acheiving the same final tooth position as the last approved clincheck
Other (specify):
3. Tooth Movement Restrictions
None (move all teeth)
These specific teeth should NOT be moved RIGHT SIDE
1
2
3
4
5
6
7
8
Upper Right
Lower Right
1
2
3
4
5
6
7
8
Upper Right
Lower Right
These specific teeth should NOT be moved LEFT SIDE
1
2
3
4
5
6
7
8
Upper Left
Lower Left
1
2
3
4
5
6
7
8
Upper Left
Lower Left
4. Attachments
Place attachments as needed
Do NOT place attachments on these teeth RIGHT SIDE
1
2
3
4
5
6
7
8
Upper Right
Lower Right
1
2
3
4
5
6
7
8
Upper Right
Lower Right
Do NOT place attachments on these teeth LEFT SIDE
1
2
3
4
5
6
7
8
Upper Left
Lower Left
1
2
3
4
5
6
7
8
Upper Left
Lower Left
5. Existing Attachments
Virtually remove all existing attachments in scan and place new attachments as needed
Virtually remove only selected attachments in scan and place new attachments as needed
Virtually remove all optimized attachments (keep conventional) in scan and place new attachments as needed
Keep all existing attachments (tooth movement efficacy might be compromised)
6. IPR
Perform IPR as needed
Do not perform any IPR
Do not perform IPR on selected contacts
1
2
3
4
5
6
7
8
Upper Right
Lower Right
1
2
3
4
5
6
7
8
Upper Right
Lower Right
Do not perform IPR on selected contacts
1
2
3
4
5
6
7
8
Upper Left
Lower Left
1
2
3
4
5
6
7
8
Upper Left
Lower Left
IPR Performed for previous clincheck tx plan
IPR was performed as prescribed
No IPR was performed
IPR performed as specified IPR report interface
7. Precision Cuts
None
Same placement as previous tx plan
Place precision cuts using my Clinical Preferences
Place precision cuts as specified in Precision Cuts Interface
8. Residual Space
None
Close the following residual spaces (specify amount of residual space present)
Your answer
9. Treatment Instructions
Upper Arch
Your answer
Treatment Instructions
Lower Arch
Your answer
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