Print Form DOCTOR: PATIENT’S NAME: EMAIL: LICENSE NO: ADDRESS/CITY: STATE/ZIP: PHONE: DATE SHIPPED: RUSH APPT DAY AM PM If you prefer to draw your appliance please print this Rx and fax to 301-279-0865 Please enter the Name of File you are going to Upload AFTER you fax your appliance form: 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 InvisibleToothTooth 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: Please Send :Mailing labelsPrescriptionsBoxes Please enter the Name of File you are going to Upload: Click on File Upload in the Menu AFTER you Send this Email Form!
