Prescription Form

Submit a New Case

Complete all sections of the prescription form. Our Nemocast Designer team will review and contact you within 24 hours.

Patient Name

Doctor Name*

Email Address*

Treatment Purpose

Arches to Treat

Attachments Placement

Attachments Timing

Match Upper to Lower Midline?

Upper Midline

Lower Midline

Correct Anterior Crossbite?

Correct Posterior Crossbite?

Will Teeth Be Extracted?

Regarding Spaces

Rehabilitation Timing

Deepbite Management

Openbite Management

Accept Bite Rises During Treatment?

Molar / Canine Class I Goal

Profile Complaints?

Third Molar Extraction?

IPR Required?

Root Segmentation?

Airway Segmentation?

Lip Line Analysis?

Treatment Notes / Special Instructions

File Downloading Link (Google Drive, WeTransfer, etc.)

Upload Files (STL, OBJ, ZIP, PDF, JPG, PNG — max 50MB each)

Drop files here or click to browse

STL, OBJ, ZIP, PDF, JPG, PNG

By submitting, you confirm that all prescription information is accurate and complete.

🔒 Secure submission⚡ 24hr response🦷 Nemocast Designer workflow📦 5-day delivery