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TMJ SLEEP APNEA FORM

​Submitting your TMJ and Sleep Apnea cases has never been easier.Our secure, user-friendly online form allows dental professionals to submit detailed case information, appliance preferences, and supporting documents directly to our lab.Designed with convenience and efficiency in mind, this form ensures your patients get the customized care they need—faster.

TMJ & Sleep Apnea Prescription Form

Doctor & Clinic Information
Doctor’s Name
License Number
Email Address
Phone Number
Order Date
Patient Information
Patient Name
Patient Age
Delivery Date
Preferred Delivery Time
Delivery Address
02:30 PM
Day Orthotic Selection
Please select the desired Day Orthotic type
Date of Phonetic Bite Registration
Adjustments from "0"

No Further Action Needed

Please Fill Out the Form Below

Measurements
Midline Deviation
Night Orthotic Selection
Please select the desired Night Orthotic type
Clasp Type
Type of Bite Registration
Adjustments from "0"

No Further Action Needed

Please Fill Out the Form Below

Measurements
Midline Deviation
Sleep Appliance Selection
Please select the desired Sleep Appliance
Optional Features
Additional Comments
Electronic Signature
Office Use Only
Notes

Thank you for contacting us. We will reply within 48 hours of receiving your message.

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