Mendivil Orthodontic Appliances
ESSENTIAL INFORMATION…
Doctor Name
Practice Information
Address
Phone
Patient Name
Chart #
Rx Date
Patient case turnaround times are determined from the date our laboratory receives the prescription. Please allow 4 to 6 working-business days for appliance processing.
ORTHOTIC HARD/SOFT NIGHT GUARDS
Upper
Lower
Orthotic Night Guard
Orthotic Day Guard
Orthotic H/S Night Guard
Orthotic H/S Day Guard
Premium Hard/Soft Design
Ortho Retainer+ Design
CLEAR ALIGNERS & RETAINERS
Upper
Lower
Direct Print 4D Aligner System
Ortho Aligner+ Clear System
Ortho Retainer+ Pontic
Shade Color _______________
Ortho Retainer+
Circle Teeth on Diagram
R
L
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
Special Instructions
Save RX
Clear Selection
Orthodontic Appliance Rx Form
EXPANSION APPLIANCES
Fixed & Removable Appliances
Upper
Lower
Haas Expander
Haas Primary Expander
Compact Expander
Compact Primary Expander
Schwartz Appliance
Quad-Helix Appliance
Comfort RPE
Standard RPE
Fan Expander
Arnold Appliance
Auxiliary Options
Cross Over Lap Springs
Reverse Head Gear Hooks
DISTALIZATION APPLIANCES
Fixed Acrylic Distalizer
M-Slider Appliance
Unilateral (1)
Upper Right
Upper Left
Bilateral (2)
Acrylic Options
Anterior Bite Plane
SPACE MAINTENANCE
Fixed Holding Appliances
Upper
Lower
Trans Palatal Arch (TPA)
Palatal Arch Appliance (PAA)
Lower Lingual Arch (LLA)
Nance Appliance
Fixed Bite Plane Appliance
Band & Loop Space Maintainer
HABIT APPLIANCES
Fixed Appliances
Upper
Lower
Tongue Rake Appliance
Tongue Fence Appliance
HAWLEY RETAINERS
Retainer Designs
Upper
Lower
Hawley with C-Clasp
Wraparound with Adams Clasp
Hawley with Adams Clasp
Wraparound with Supports
Phase 1 Hawley
3-3 Fixed Retainer
Spring Aligner Appliance
Ricketts Retainer
Pontic “Flipper” Appliance
Shade Color _______________
Springs & Auxiliaries, Acrylic Options
Finger S Springs
Single Helix
Double Helix
Helix to Close Space
Strut to Hold
Bloore Spring
Anterior Bite Plane
Incline Bite Plane
Posterior Bite Plane
DESIGN YOUR ACRYLIC RETAINERS & EXPANDERS
Designer Acrylic ______________________________________
Acrylic Color __________________________________________
Decals ___________________
Glitter Color ___________________