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DOCTOR:
PATIENT’S NAME:
EMAIL:
LICENSE NO:
ADDRESS/CITY:
STATE/ZIP: PHONE:
DATE SHIPPED:
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APPT DAY AM PM
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Teeth

Retainers

Fixed Appliances

Functional Appliances

UpperLowerWraparound Clasps Transpalatal Bar Sagittal
Lingual Arch 2-wayMandMax
AdamsArrowBallCOther Bonded Lingual Retainer 3-wayMandMax
SpringsFingerOSolderedS 3x3 w/2 pads 3x3 w/6 pads SchwartzMandMax
Blle Plate AnteriorPosteriorIncline Nance Omit occlussal coverage
Plastic Pontic Tooth Shade Space Maintainer Twin Block
Habit Rake Type Bead Habit Type Bionator
Screws 8mm11mmFan Quad Helix Herbst
3-way Carve Bands YesNo W expansion SPLINTS
ShamyCetlinOther Hass Flat Plane
  RPE Cuspid Rise

Spring Aligner

Bonded RPE Hard/Soft
3x34x4ModifiedExtensionReset Direct Bond w/Tray 3x3 Other
Leave as isDo Not StripStrip contacts as indicated Pendex

Acrylic

PinktoneClearOther
Decal


Digital or Printed Models

BothUpperLower
Minimal base 3-5mm per arch
Full base 2 3/4” (70mm) total height
ToothTooth 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

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