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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