Transcription of Metal Appliance Rx
1 CIRCLE CROWNS TO BE SEATED CROWNS & BANDSDOCTORACCT#ADDRESSCITYSTATEZIPPHONE FA XEMAILPATIENT NAMEDATE SHIPPED DATE NEEDED**Date needed should be at least 1 day before appointment date. APPROVAL TO CHARGE EXPRESS SHIPPING TO RETURN ON DATE NEEDEDNOTIFICATIONCONTACT ME REGARDING CASESPECIAL INSTRUCTIONS ON FILECIRCLE BANDS TO BE SEATED SEND ADDITIONALRx FORMSMAILING LABELS/SUPPLIESADDRESS CHANGE NEW ACCOUNTM etal Appliance RxSpecialty appliances provides and fits: Band(s) Crown(s) ROC(s) Crowns or Bands enclosed with case OFFICE USE: 1 2 3 4 + PD: SA DR MODELS: U L BOTH BANDS CROWNS BROKEN IMPRESSIONS: U L BOTH DISINFECT: QA IN: FINAL INSP.
2 Habit Appliance Crib Spurs BluegrassFixed Bite Plane RickanatorE-Arch Ta n d e m OTHER APPLIANCESRL 7 6 5/e 4/d d/4 e/5 6 7 7 6 5/e 4/d d/4 e/5 6 7 RL 7 6 5/e 4/d d/4 e/5 6 7 7 6 5/e 4/d d/4 e/5 6 7 OCCLUSAL RESTS PER DIAGRAMOCCLUSAL RESTSRL 7 6 5/e 4/d d/4 e/5 6 7 7 6 5/e 4/d d/4 e/5 6 7 RLStandard Hyrax RPES tandard Haas RPEA crylic Bonded RPEDeLuke Contoured RPEE xspider Fan ExpanderLower Fixed Expander MSE-MARPEQuad HelixTranspalatal Arch Lingual Arch: LowerNance ApplianceSpace Maintainer (Specify)HOLDINGEXPANSIONAW Tubes.
3 018 .022 Upper Lower Headgear TubesLip Bumper Tubes Lingual Sheaths Hooks (Specify)Lingual Seating LugsDebonding Holes V e n t Holes V e r t i cal SlitsRemove Occlusals for Crowns (ROC )Debonding WiresDebonding ScrewsAcrylic ColorACCESSORIESR LPendulum OriginalPendex (w/ Expander)T- Re xPHD ApplianceMDA ApplianceRapid Molar DistalizerHorseshoe JetDistal Jet Halterman ApplianceDISTALIZATIONOUTRLRINLMINICLICK OTHERSPECIAL INSTRUCTIONS(800) 522-4636 IN GEORGIA (678) 513-4408FA X (678) SIGNATUREL icense #ExpirationiTeroTr i o sCarestreamOmnicam3 MOther:DIGITAL SCAN TAKEN WITH.
