Imaging Service PrEscription Form

Practice Name:
E-mail Address:
Address:
City:
State:
Zip:
Imaging Information
Patient Name:
Note: Please ensure all file names do not include any special characters to include periods, hyphens, or underscores and the file sizes are smaller than 5MB prior to uploading them to this site.
Upload Image (frontal):
Upload Image (lateral):
Upload Image (full face):
Treatment Plan: (Please specify teeth to image here)
Shade Desired:
Do you desire balance of gingival tissue?
By checking this box I agree that to my knowlege the above information is accurate:

*Please Note: Your order was not successfully submitted until you receive a “Confirmation” from our website. If you do not receive this confirmation, please phone (317) 841 – 1161 or submit your photos & treatment plan directly to info@envisionasmile.com . Thank you.

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Imaging Service PrEscription Form

Imaging Information

Imaging Services

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