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Doctor Form

To Open Patient Case

Doctor's Name*

Email*

Doctor's Phone*

Clinic Address*

Clinic Phone*

Patient's Name*

Patient's ID*

Patient's Date of Birth*

יום

חודש

שנה

Please upload a photo portfolio that includes: Panoramic, Facial and dental photographs, Upper jaw intraoral scan, Lower jaw intraoral scan, Bitewing intraoral scan.

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luxdentalsupply@gmail.com

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