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Frequently Used Forms

Click below to print the forms you need to offer feedback, to make requests and to provide the clinical data that enables us to make continual improvements to the SureSmile system.

SureSmile® Case Transfer Form - Effective for Standard Case Starts beginning March 01, 2021.

Location Change Request Form - Use to add, remove or change addresses for a practice site.

Archwire Discrepancy Report - Use to report issues with archwires and archwire installation.

Treatment Discrepancy Request Form - Use to report any clinical inconsistencies between a patient's setup and treatment results.

Validating CBCT Scanner with a Phantom Scan - Instructions describing how to set up and perform the phantom scan. Also explains which data needs to be sent to SureSmile for evaluation.

CBCT Validation Request Form - Your CBCT scanner calibration must be verified by Dentsply Sirona before CBCT data can be accepted. Fill out and submit this form to start the 2 to 3-week CBCT validation process.

SureSmile® Treatment Consent Form - Patient form indicating that they understand the risks or options available for orthodontic treatment.

 

The files above are in PDF format and require Adobe Acrobat reader. If you do not have Adobe Acrobat reader, download it here.