Clear Aligner Rx eForm
Please complete the form below. All fields indicated by * are required.

Dentist Information

Patient Information

Periodontal Status

Treatment

Midline

Anterior Posterior Relation

Crowding

These Terms & Services ("Agreement") govern the provision of clear aligner services by Melorin, LLC ("Company") to the licensed dentist ("Dentist") identified in the accompanying form. By submitting the form, the Dentist agrees to be bound by these terms and conditions. (1) Services: a. The Company will provide clear aligner therapy services to the Dentist's patients as per the treatment plan outlined in the accompanying form. b. The Company will manufacture and supply the necessary clear aligner trays according to the treatment plan specifications. (2) Treatment Plan: a. The Dentist will provide the Company with the necessary diagnostic records, including clinical examination findings, radiographs, photographs, and impressions. b. The Dentist will review and approve the proposed treatment plan provided by the Company before initiating the clear aligner therapy. c. Any modifications to the treatment plan must be communicated to the Company in writing and agreed upon by both parties. (3) Responsibilities: a. The Dentist will ensure that the patient's oral health is assessed and monitored throughout the clear aligner treatment. b. The Dentist will inform the Company promptly of any patient-specific issues, complications, or changes in the treatment plan. c. The Dentist will provide accurate and complete patient information necessary for the provision of clear aligner services.
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