Dentist/Practice Details First name *Last name *Practice Name *Street address *Flat, suite, unit, etc. (optional)Town / City *State / County (optional)Postcode / ZIP *Country/Region *United Kingdom (UK)Phone *Email address * Patient Details First Name * Last Name * Date of Birth * Implant Order Details Order Type * <--- Teeth in a day Package ---> Teeth in a day Surgical – Standard Teeth in a day Surgical – Premium Teeth in a day Surgical – Comprehensive <--- Full Arch Prosthetics ----> Final Acrylic Hybrid Package Final Monolithic Zirconia Packageds <--- Prosthetics Acrylic ---> Acrylic Denture 1-3 units Acrylic Denture 4-8 units Acrylic Denture 9+ units Full Jaw Denture Full Mouth Denture <--- Mouth Guards ---> Mouthguard Bleaching Tray Essix Retainer Surgery Date * Return Date * Shade * Select all Upper Right Teeth (optional) Select all Upper Left Teeth (optional) Upper Right Teeth (optional) 11 12 13 14 15 16 17 18 Upper Left Teeth (optional) 21 22 23 24 25 26 27 28 Lower Right Teeth (optional) 48 47 46 45 44 43 42 41 Lower Left Teeth (optional) 38 37 36 35 34 33 32 31 Select all Lower Right Teeth (optional) Select all Lower Left Teeth (optional) Instructions * Upload Section Please ensure scans and pictures are uploaded, for larger files please send these to orders@welltechlab.com Scans (optional) Select File or Drag & Drop Uploading... Delete Select File or Drag & Drop Uploading... Delete Select File or Drag & Drop Uploading... Delete Select File or Drag & Drop Uploading... Delete Select File or Drag & Drop Uploading... Delete Select File or Drag & Drop Uploading... Delete Select File or Drag & Drop Uploading... Delete Select File or Drag & Drop Uploading... Delete Select File or Drag & Drop Uploading... Delete Select File or Drag & Drop Uploading... Delete Pictures (optional) Select File or Drag & Drop Uploading... Delete Other (optional) Select File or Drag & Drop Uploading... Delete Posted Items (optional) Physical impressions Bite registration Other Your order Product Subtotal × 1Implant Crown & Bridge × 1 £0.00 Subtotal £0.00 Total £0.00 Since your browser does not support JavaScript, or it is disabled, please ensure you click the Update Totals button before placing your order. You may be charged more than the amount stated above if you fail to do so. Update totals Your personal data will be used to process your order, support your experience throughout this website, and for other purposes described in our privacy policy. Place order Username or email *Required Password *Required Remember me Login Lost your password?
