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Rx ONLINE FORM

Submitting your dental cases has never been easier. Our Rx Online Form is a secure, streamlined solution for dentists and orthodontists to upload prescriptions, case details, and supporting documents directly to our lab.

Rx FORM

Doctor & Clinic Information
Doctor’s Name
Email Address
Phone Number
Order Date
Patient Information
Patient Name
Patient Age
Delivery Date
Preferred Delivery Time
Delivery Address
02:30 PM
Tooth Selection
Upper Teeth
Instructions
Lower Teeth
Material Specification
Occlusion & Contact Preferences
Centric Contact
Lateral Excursion
Margin Design
Margin Adaptation
Labial Margin
Pontic Design
Please select the desired pontic design:
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Cone-gray.png
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Contact (Embrasure) Design
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Normal-gray.png
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Special Shade Selection
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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