Existing Customer (requires Name & Account # or Tel #) New Customer

Ship and Bill To: *Name  Account # *Street Address  *City  *Province  *Postal Code  *Telephone  Fax  E-mail    Bill to: (if different from Ship To) Name  Street Address  City  Province  Postal Code  Telephone  Fax  E-mail

*Required fields for new customers

Date Order Placed Required Arrival Date of Shipment Ordered By

Order Comments

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Bracket Type:

Elite Opti-MIM (Regular Profile)   Delta Force   Golden Brackets Elite Opti-MIM (Nickel Free)   Elite Vertical Slot   Illusion Plus (Ceramic) Elite Opti-MIM (Low Profile)   Mini-Alexander   Illusion (Ceramic) (Silver Slot) Elite Mini-Twin   Mini Edgewise   Envision (Composite) Elite Medium Twin   Coralex   Envision (Composite) (Gold Slot)

Prescriptions:

Roth   Andrews   MBT   Bioprogressive   Nanda

.018   .022

Upper Tooth Type QTY w/o Hooks Central Right   Central Left   Lateral Right   Lateral Left   Cuspid Right Cuspid Left 1st Bic. Right 1st Bic. Left 2nd Bic. Right 2nd Bic. Left Upper 1st Molar Convertible Buccal Tube (CBT) Upper 1st Molar Convertible Buccal Tube (OCBT) Upper 1st Molar Convertible Double Buccal Tube (DBT) Upper 1st Molar Convertible Triple Buccal Tube (TBT) Upper 1st Molar Convertible Standard Buccal Tube (STD) Upper 2nd Molar Mini Buccal Tube (with distal extension) Upper 2nd Molar Mini Buccal Tube (without distal extension) Lower Tooth Type QTY w/o Hooks Central Right   Central Left   Lateral Right   Lateral Left   Cuspid Right Cuspid Left 1st Bic. Right 1st Bic. Left 2nd Bic. Right 2nd Bic. Left Lower 1st Molar Convertible Standard Buccal Tube (STD) Lower 1st Molar Convertible Double Buccal Tube (DBT) Lower 1st Molar Lip Bumper Tube (LBT) Lower 2nd Molar Mini Buccal Tube (with distal extension) Lower 2nd Molar Mini Buccal Tube (without distal extension)