ORDER FORM

Upper Arch

In case of extraction please specify before or after bonding.

Molar Relation 

Right:

Canine Relation

Right:

Upper

BRACKETS

Please specify - per arch - on which teeth you need the brackets i.e. 6-6 upper & lower arch:

OTHER REMARKS / REQUIRMENTS i.e. customized band, TPA tube etc.

• High quality digital models and impressions must be provided.

• Any four arch wires - per arch - will be provided with each case.

• Please mention invoice number as payment reference.