Splint Rx - Great Lakes Orthodontics

SPLINT / DEPROGRAMMER
PRESCRIPTION
Great Lakes Orthodontics, Ltd.
200 Cooper Avenue, Tonawanda, N.Y. 14150
Toll Free: 800-828-7626
PLEASE PRINT
Account # LO
B
I
L
L
I
N
G
A
D
D
R
E
S
S
Customer Used: r GLO Acct r 2 Day On Call
r Disinfected
DATE
SHIPPED:
(i.e., ortho, GP, pedo, prostho, oral surgeon, commer. lab)
DOCTOR:
0 1 2 3 4 5 6 7 8 9
Rcvd:
B#Via:
(Specify if ship to address is different)
DATE DUE:
CITY:
PHONE: (
Provide
Country &
FAX:
(
City Code
Incoming # cases 1 2 3 4 5+
r Portal Upload - No Frt (99) r Cust Acct - No Frt (99)
PO #
PRACTICE TYPE:
ADDRESS:
LAB USE ONLY
STATE: ZIP:
)
1 day before
appointment
)
EMAIL:
PATIENT:
Needs DD Call
LPD/Shp:
Rec:
NO BITE / MDL - B / C
Doc#
Digital ID#
Please Provide: rBoxes rLabels rRx (specify appl. type):
__________________________________Qty:_____________ rAppliance Protection Program (additional fee)
AGE:
PLEASE PRINT
QC:
IMPORTANT! Always retain models and bite until appliance is seated.
Damage to models may occur during fabrication, please mark Rx if duplication (additional fee) of model(s) is required.
PLEASE READ
If you would like us to follow the specifications of a particular clinician,
please specify:
Articulator used: _________________________
Splints
r UPPER
r LOWER
r DIGITAL Flat Plane (No Guidance)
r DIGITAL Full Contact with Anterior Guidance
r Flat Plane (No Guidance)
r Full Contact with Anterior Guidance
r Anterior Repositioning (Pull Forward)
r Overlay (1.5mm Base Plate)
Options: r Add Occlusal Acrylic (not articulated, equilibration required)
r Tanner with lingual bar - Lower Only
r Gelb
Special Instructions:
NOTE: To compensate for curve of Spee, please:
r Increase opening
r Provide steeper guidance
Deprogrammers
r UPPER
r LOWER
r Great Lakes Anterior STANDARD (Spear)
r Mini 2 x 2 contact (5 x 5 coverage)
r 2 x 2 contact STANDARD, VDO no interferences
r 2 x 2 contact, VDO just out of contact
r Kois (Retainer Style)
r Cranham
r Dawson B Splint
r Maxillary only r Dual Arch
Material
r Splint Biocryl (Plus Acrylic) STANDARD
r Splint Biocryl (NO Acrylic)
r Cold Cure (Acrylic)
r Hard/Soft
r VariflexTM (Thermal Active)
r Tooth Shade Acrylic
r Biocryl ICE
Acrylic Coverage
r 3-5mm Tissue STANDARD r No Tissue Contact
Clasping
r Ball STANDARD
r None
r Other:_________________
r Master Rx on File #_____________________
License #____________Dr. Signature:________________________
Lab Use Only
r Dup
r DM
r No Bite
Art #____________ DRPS____________ LPS____________
r SII
r SIII
r DC
rW
r ARTX
r STRS
r HAN
r PAN
r Kavo
DR ART / DR BITE FORK / DR JIG
Toll Free: 800-828-7626 Local: 716-871-1161 Fax: 716-871-0550 Email: [email protected] Website: www.greatlakesortho.com
©Great Lakes Orthodontics, Ltd. S-23 Lab FM-6 Rev 5/12/16