• Practice Details

  •  -

  • Please use a street address as we cannot deliver to PO Boxes.

  • Patient Details

  • Script Details - Appliances

    Please complete all questions in this section.

  • pl_07 defines # printed models required

  • IMPORTANT: Lateral Ceph and OPGS/X-rays MUST be provided for all Dr Galella Reviews.

    Please note that Case Reviews will incurr a $65 fee.

  • Patient Preferences

  • Download a PDF of the colour chart here.

  • Please advise your patient that colour matching is on a best-effort basis.

    Exact colour matching is impossible due to variations in computer monitors, printing dyes and inks, as well as the human eye.  However, all reasonable effort will be made to match your preferred colour to the appliance.

  • Patient Photos

  • Please drag and drop all patient images in the box titled "Upload Images Here",

    • JPEG File format only
    • Include Patient Name in all filenames (i.e. PatientName0001.jpg)

    We encourage as many of the sample images below as possible for successful case submission.  You may also upload additional files such as:

    • Lateral Ceph
    • OPG / X-Rays

    IMPORTANT: Lateral Ceph and OPGS/X-rays MUST be provided for all Dr Galella Reviews.

    Please note that STL files will be uploaded in a later section of this form.

    Please hover over each image once dropped into the upload section & confirm you have copied the correct files, and ensure you press "Begin Upload."

  • Intraoral Scans & Models

    Please indicate how patient models will be supplied.

  • Intraoral Scan Files

    If you use an Intraoral scanner, please export all files in STL file format and upload here.

    You must supply 2 STL Files otherwise the case will be rejected.  Please label with patient first & last name, and upload, eg:

    1. PatientNameUpperArch.STL
    2. PatientNameLowerArch.STL

    in the below Intraoral STL File Upload box.  If the STL files are larger than 20MB, please zip the files prior to dragging across and uploading.

  • Please Press "Begin Upload" to start the upload of your STL files before progressing to the next page.

  • If you do not have an Intraoral scanner or are unable to upload STL files, we are able to scan patient models on your behalf.

    Please ensure we receive your models in a timely fashion, as all lead times are calcuated from completed applications have been received & approved.

    Please ensure you follow the Model Guidelines and Case Submission documents below to ensure timely progression of your case.

  • Lead Times

  • Whilst we endeavour to expedite every case, processing times can vary. A Dr Galella case review requirement is likely to impact on processing times. Please be mindful of this when scheduling patient appointments:

    In order to ensure the most expeditious processing of your case, please ensure that all the necessary Case Submission information below is provided:

    • Patient photos uploaded as per script template
    • Intraoral Scans as STL files uploaded as per script template.
    • If using our model scanning service, Stone models are made in accordance with "Model Guidelines" and sent in accordance with "Rapid Smiles Case Submissions" guide.
    • Any other specific relevant documentation or requests pertaining to the case.

    Allow a minimum of 4 weeks from receipt of completed Case Submission to delivery.

    NB: Please confirm delivery date before scheduling your patient visit.

  • Your contact Details

  • All correspondence regarding this case will be directed to the email address below.  Plesae ensure your have entered the correct details as this will adversely affect the delivery time of your script. If you need to change this address, please re-visit the first page of this form.

  • Submission

  • Please ensure you have included all of the following items before submitting this form.

  • You must upload patient images to submit this prescription.

  • You must upload STL Files to submit this prescription.

  • Please be patient after you have pressed submit. The upload process may take a number of minutues, however when completed succesfully the page will refresh and confirm sucessful submmission.

  • Should be Empty: