Print Now Orthodyne Laboratories, Inc. Digital Prescription

DOCTOR:
EMAIL:
LICENSE NO:
ADDRESS/CITY:
STATE/ZIP: PHONE:
DATE SHIPPED:
 RUSH
APPT DAY  AM  PM
PATIENT’S NAME:
  If you prefer to draw your appliance please print this Rx and fax to
301-279-0865

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AFTER you fax your appliance form:

Teeth

Retainers

Fixed Appliances

Functional Appliances

 Upper Lower Wraparound  Transpalatal Bar  Sagittal
Clasps  Lingual Arch  2-way Mand Max
 Adams Arrow Ball C Other  Bonded Lingual Retainer  3-way Mand Max
Springs Finger O Soldered S  3x3 w/2 pads  3x3 w/6 pads  Schwartz Mand Max
Blle Plate  Anterior Posterior Incline  Nance  Omit occlussal coverage
Plastic Pontic Tooth Shade  Space Maintainer  Twin Block
Habit Rake Type  Bead  Habit Type  Bionator
Screws  8mm 11mm Fan 3way  Quad Helix  Herbst
Carve Bands  Yes No  W expansion SPLINTS
 Shamy Cetlin Other  Hass  Flat Plane
   RPE  Cuspid Rise

Spring Aligner

 Bonded RPE  Hard/Soft
 3x3 4x4 Modified Extension Reset  Direct Bond w/Tray 3x3  Other
 Leave as is Do Not Strip Strip contacts as indicated  Pendex

Acrylic

 Pinktone Clear Other
 Decal


Digital or Printed Models

 Both Upper Lower
 Minimal base 3-5mm per arch
 Full base 2 3/4” (70mm) total height
 Tooth Tooth Shade  Pendulum
RESET TEETH
R  Uper R 3  Uper R 2  Uper R 1  Uper L 1  Uper L 2  Uper L 3 L
3 2 1 1 2 3
3 2 1 1 2 3
 Lower L 3  Lower L 2  Lower L 1  Lower R 1  Lower R 2  Lower R 3
 Distal Jet
 Jet Expander
 Bluegrass
 Tandem
 Other

Special Instructions:

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