Suite 100-1750 Courtwood Crescent, Ottawa, Ontario K2C 2B5

Fax-613.701.4297

Doctor’s Signature License #

Additional Instruction:

Tel-613.680.6016 www.watersedgedentallab.com

“The single biggest problem in communication is the illusion it has taken place” - George Bernard Shaw *All Appliances Available Upon Request. Please Call for More Information

Specialty:

Standard

Additional Instruction:

Type of Articulation:

Follow my Preferences on File Please Call

Lost Appliance Insurance

Maxillary

Mandibular

Maxillary Vacuum Form Protrusive Measurement mm Mandibular Acrylic Kois

Anterior Deprogrammer:

Schwartz One Screw Two Screw Three Screw

Active Spring Aligner Active Invisible Retainer

Functionals & Expanders:

Open Closed Hold Midline Screw

Maxillary Expansion Screw Without Expansion Screw

Hawley Adapted 3x3 Welded 6x6 Wrap Around 7x7

Mandibular Expansion Screw

Saggital:

Bionator:

Twin Block:

Removable Appliances:

Thumb Tongue 3x3 Wire 3x3 Cast V Loop

V Loop Habit Breaker: Lingual Retainer:

Fixed Appliances:

Hyrax Super Screw Rapid Palatal Expander:

Transpalatal Arch

Band & LoopBand & Loop Space Regainer

Lingual Arch

Nance Button

Wilson 3D Fixed Removable

Snore Guard / Obstructive Sleep Apnea:Sleep Ez (Semi-Adjustable) Fixed Position (Protrusive Bite required) EMA Elastic Mandibular Advancement (Semi-Adjustable)

Splints:

Doctor:

Address:

Rx Date:Patient:

Return Date:

Time Requested:

Last, First Age / Sex

Acrylic Type:

Maxillary Flat Group Function Mandibular Cuspid Rise Protrusive Guidance Orthotic

Hard Acrylic Thermo�ex Hard Flex

Color:

Pressure Formed Laminates:

Sportsguard: Recreational Boxing Weightlifting One Layer Two Layer Bleaching Trays: Maxillary Mandibular Invisible Retainer: Maxillary Fluoride Tray: Maxillary Mandibular

Mandibular

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 88 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8