Maverick Clinical Preference Form Please note: Written instructions on the script will always supersede preferences saved to your account. Preferences may be changed anytime. OFFICE INFORMATION Practice Name: Street Address: City: State: Zip Code: Office Phone: Office Email: Doctor Name: Doctor Cell #: Doctor Email: How would you prefer to be contacted? Mark all that apply. Email OfficeEmail DoctorCall OfficeCall Cell *I opt in to receive daily case status emails Preferred Email: BILLING PREFERENCES Address (If different than shipping address) Billing Street Address: Billing City: Billing State: Billing Zip Code: Billing contact name: Billing contact email: *I would like my statements emailed to me *I would like to sign up for Auto Pay ADDITIONAL TEAM MEMBERS Please list any additional team member names, phone #, and emails: CROWN & BRIDGE PREFERENCES Occlusal Clearance: Light Centric (Default)In occlusionOut of occlusion __ mm If you selected “Out of occlusion __ mm,” please specify below: Interproximal Contacts: Medium (Default)LightTight Unclear Margins: —Please choose an option—Digital scans: Send margin verification emailPhysical cases: Return to Dr. to ditch dieLab to proceed as best as possible (Remake fees may apply)Please contact me Insufficient Clearance: —Please choose an option—Reduce opposing by __ mm maxReduce opposing as needed & markReduction copingPlease contact me If you selected “Reduce opposing by __ mm max,” please specify: Bridge Pontic Design: Modified ridgelap (Default)OvateFull ridge IMPLANT PREFERENCES Abutment Manufacturer: —Please choose an option—Compatible abutmentsOEM specific abutments (Additional fees apply) Abutment Type: —Please choose an option—Screw retainedCement retained Gingival Emergence: —Please choose an option—No tissue blanching (Follow exact gingival contours from impression)Moderate blanching (Tissue adapts in ~5 minutes)Make emergence ideal (May require tissue modification) In cases of lingual implant position: —Please choose an option—Ridgelap porcelain for better appearanceNever ridgelapReduce buccal tissue to improve emergence position (Requires tissue modification)Contact me When screw retained is requested, but not possible after lab evaluation: —Please choose an option—Switch to angled crew channel abutment (Additional fees apply)Switch to cement retainedContact me REMOVABLE PREFERENCES Occlusal Splint Material: —Please choose an option—PrintGuard3D (Default for scans)Traditional hard/softTraditional hard Occlusal Splint Design: Flat plane (Default)Anterior ramp (Additional fees apply) Metal Partial Clasps: Wrought wire (Default)Pink flexible (Additional fees apply)Clear aesthetic (Additional fees apply) Teeth Selection: —Please choose an option—Maverick stockSpecial order (Additional fees apply) If you selected “Special Order,” please specify: