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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Upper Tooth Type
QTY
w/o Hooks
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
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)
Prescriptions:
Roth
Andrews
MBT
Bioprogressive
Nanda
Welding Comments:
(NOTE: All 1st and 2nd Molar Brackets will be welded to ordered Bands unless otherwise noted in Comments box)
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LINGUAL ATTACHMENTS for BANDS:
Bicuspids
1st Molar
2nd Molar
Upper
Blank
Button
Lug
Sheath
Cleat
Lower
Blank
Button
Lug
Sheath
Cleat
Order Comments
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PLAIN BANDS
Plain Bands Only
Bracket Slot Size
.018
.022
Facebow Tube Size
.045
.051 (special order)
BICUSPID BANDS
1st Bicuspid
Right
Left
Right
Left
Right
Left
Right
Left
2nd Bicuspid
Right
Left
Right
Left
Right
Left
Right
Left
TEMPRA MOLAR BAND (FULL TEMPERED)
Etched
Non-Etched
Tempra 1st Molar
Right
Left
Right
Left
Right
Left
Right
Left