Rx Order Form

Please complete and submit the following form. * marks required fields. Linked items in blue will open in a new browser tab so you can toggle back to the form to enter information.

Order Information
* Doctor:
* License #:
* Address:
* City:
* State:
* Zip:
* Email:
* Phone:
* Patient Name/ID:
* Date Sent To Lab:
* Date Needed:
Color Upper:
Color Lower:
Order Notes:
Type of Appliance
  UPPER   LOWER

3D DIGITAL

3D Printed Work Models from your .stl scans  

REMOVABLE APPLIANCES

Standard Hawley Retainer  
Wraparound Hawley  
Maxillary Expansion Appliance    
Habit Correctors Thumb Sucking  
Tongue Thrust  
Bite Planes Anterior  
Posterior  
Accessories for Removable Appliances Adams Clasp  
Ball Clasp  
Circumferential Clasp  
"C" Clasp  
Springs  
Splint  
Nightguard  
Invisible  
  UPPER   LOWER

FIXED APPLIANCES

Rapid Palatal Expansion Appliance
Hyrax  
Compact  
Mandibular Mid-line Expansion  
Nance Appliance  
Space Maintainer  
Lingual Arches Molar to Molar  
Cuspid to Cuspid  
Habit Correctors Thumb Sucking  
Tongue Thrust  
Accessories for Fixed Appliances Space Maintaining Spurs  
Springs  
Molar Bands  
Space Regainers Arnold  
Quad Helix  
Case Design

This optional section allows you to indicate the extent of acrylic and the location of springs & clasps by marking up the mouth diagram image. Here are two ways to mark up the image to attach below.

Attach marked up Appliance Arch Diagram: please upload a PNG, JPG, GIF or PDF file.

Electronic Signature

I, the submitter of this form, warrant the truthfulness of the information provided in this application and understand checking the Acceptance Checkbox constitutes a legal signature.

* Submitter Full Name:
* Acceptance Checkbox: