new lab order form jp.indd - Lingualtechnik
new lab order form jp.indd - Lingualtechnik
new lab order form jp.indd - Lingualtechnik
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
To be filled out by TOP-Service <br />
Patient (Surname) ___________________________ (First name) ___________________________<br />
<br />
Orthodontic practice _____________________________________________________________<br />
<br />
Address ________________________________________________________________________________________________________________<br />
<br />
Contact (Tel.) ________________________________________________ (Fax) ______________________________________________________<br />
<br />
Date and time of bonding _______________________________________________________________________________________________<br />
<br />
Please fully complete the treatment plan (in the red box) <br />
Arch to be bonded MAX MDB<br />
<br />
Setup (see notice below) MAX MDB<br />
<br />
Tray (Please tick) <br />
Lab <strong>order</strong> <strong>form</strong><br />
<br />
<br />
<br />
<br />
Silicon hard Bioplast Memosyl<br />
(non-transparent) (transparent) (transparent)<br />
<br />
Stripping MAX<br />
essential ____ mm<br />
yes, if necessary<br />
no stripping<br />
Booking <br />
(Mo - Fr 8 am - 5 pm)<br />
Tel. +49 5472 9491-295<br />
Fax +49 5472 9491-276<br />
TOP-Service für <strong>Lingualtechnik</strong> GmbH<br />
Schledehauser Straße 81 · D-49152 Bad Essen<br />
Tel. +49 5472 9491-10 · Fax +49 5472 9491-19<br />
top@lingualtechnik.de · www.lingualtechnik.de<br />
Appliance recommended by TOP-Service<br />
Remarks<br />
Bracket series<br />
MAX<br />
Ribbonwise VH<br />
Edgewise<br />
Optional Extras<br />
3-3BP 3BP TH TL TI<br />
Set of archwires MAX<br />
Wires required straight indiv.<br />
(please tick) lat. sec. lat. sec.<br />
TMA Steel SE Ni-Ti<br />
12 Ø<br />
14 Ø<br />
16 Ø N<br />
16 Ø braided<br />
16 x 22 E E N<br />
18 x 25<br />
16 x 22 N<br />
16 x 22 ET*<br />
16 x 24<br />
16 x 24 ET** E<br />
18 x 25<br />
18 x 25 (red.)<br />
17,5 x 17,5<br />
17 x 25<br />
18,2 x 18,2 E N<br />
18,2 x 25<br />
<br />
For an ex-case please indicate space closure or not<br />
Please fill in: B = bracket; T = tube; Ex = to be extracted; X = missing;<br />
casted ring = circle tooth; occlusal pad surface = shade in<br />
<br />
Stamp, date and signature<br />
<br />
I accept the terms and conditions of sale on the reverse of this <strong>form</strong>.<br />
<br />
Stripping MDB<br />
essential ____ mm<br />
yes, if necessary<br />
no stripping<br />
3-3BP = Bite plane 3-3<br />
4 wires per arch are included in the price<br />
3BP = Bite plane on 3´s<br />
ET* = Extra torque of 15°on 11/21<br />
TH = Tube with hook<br />
ET** = Extra torque of 13°on 3-3<br />
TL = Tube extra long<br />
Possible red. = laterally reduced<br />
TI = Tube with easy insertion Combinations E = recommended wire for Ex-cases<br />
3-3SL = MDB anteriors “self ligating“ 3-3 N = recommended wire for Non-Ex-cases<br />
Bracket series<br />
MDB<br />
Ribbonwise VH<br />
Edgewise<br />
Remarks<br />
Optional Extras<br />
3-3SL TH TL TI<br />
Set of archwires MDB<br />
Wires required<br />
(please tick)<br />
straight indiv.<br />
lat. sec. lat. sec.<br />
12 Ø<br />
14 Ø<br />
16 Ø N<br />
16 Ø braided<br />
16 x 22 E E N<br />
18 x 25<br />
16 x 22 N<br />
16 x 24 E<br />
18 x 25<br />
18 x 25 (red.)<br />
17,5 x 17,5<br />
17 x 25<br />
18,2 x 18,2 E N<br />
18,2 x 25<br />
Please note:<br />
We always need one silicon impression for each arch that is to be bonded - for<br />
opposing arches a plaster model is sufficient. For details regarding impression taking<br />
or other detailed in<strong>form</strong>ation please look at our website www.lingualtechnik.de or<br />
contact us directly. If you only want us to position one arch, please nevertheless<br />
always indicate if you plan any treatment for the opposing arch - even if it is<br />
<strong>lab</strong>ial.<br />
TMA Steel SE Ni-Ti
To be filled out by TOP-Service <br />
Patient (Surname) ___________________________ (First name) ___________________________<br />
<br />
Orthodontic practice _____________________________________________________________<br />
<br />
Address ________________________________________________________________________________________________________________<br />
<br />
Contact (Tel.) ________________________________________________ (Fax) ______________________________________________________<br />
<br />
Date and time of bonding _______________________________________________________________________________________________<br />
<br />
Please fully complete the treatment plan (in the red box) <br />
Arch to be bonded MAX MDB<br />
<br />
Setup (see notice below) MAX MDB<br />
<br />
Tray (Please tick) <br />
Lab <strong>order</strong> <strong>form</strong><br />
<br />
<br />
<br />
<br />
Silicon hard Bioplast Memosyl<br />
(non-transparent) (transparent) (transparent)<br />
<br />
Stripping MAX<br />
essential ____ mm<br />
yes, if necessary<br />
no stripping<br />
Booking <br />
(Mo - Fr 8 am - 5 pm)<br />
Tel. +49 5472 9491-295<br />
Fax +49 5472 9491-276<br />
TOP-Service für <strong>Lingualtechnik</strong> GmbH<br />
Schledehauser Straße 81 · D-49152 Bad Essen<br />
Tel. +49 5472 9491-10 · Fax +49 5472 9491-19<br />
top@lingualtechnik.de · www.lingualtechnik.de<br />
Appliance recommended by TOP-Service<br />
Remarks<br />
Bracket series<br />
MAX<br />
Ribbonwise VH<br />
Edgewise<br />
Optional Extras<br />
3-3BP 3BP TH TL TI<br />
Set of archwires MAX<br />
Wires required straight indiv.<br />
(please tick) lat. sec. lat. sec.<br />
TMA Steel SE Ni-Ti<br />
12 Ø<br />
14 Ø<br />
16 Ø N<br />
16 Ø braided<br />
16 x 22 E E N<br />
18 x 25<br />
16 x 22 N<br />
16 x 22 ET*<br />
16 x 24<br />
16 x 24 ET** E<br />
18 x 25<br />
18 x 25 (red.)<br />
17,5 x 17,5<br />
17 x 25<br />
18,2 x 18,2 E N<br />
18,2 x 25<br />
<br />
For an ex-case please indicate space closure or not<br />
Please fill in: B = bracket; T = tube; Ex = to be extracted; X = missing;<br />
casted ring = circle tooth; occlusal pad surface = shade in<br />
<br />
Stamp, date and signature<br />
<br />
I accept the terms and conditions of sale on the reverse of this <strong>form</strong>.<br />
<br />
Stripping MDB<br />
essential ____ mm<br />
yes, if necessary<br />
no stripping<br />
3-3BP = Bite plane 3-3<br />
4 wires per arch are included in the price<br />
3BP = Bite plane on 3´s<br />
ET* = Extra torque of 15°on 11/21<br />
TH = Tube with hook<br />
ET** = Extra torque of 13°on 3-3<br />
TL = Tube extra long<br />
Possible red. = laterally reduced<br />
TI = Tube with easy insertion Combinations E = recommended wire for Ex-cases<br />
3-3SL = MDB anteriors “self ligating“ 3-3 N = recommended wire for Non-Ex-cases<br />
Bracket series<br />
MDB<br />
Ribbonwise VH<br />
Edgewise<br />
Remarks<br />
Optional Extras<br />
3-3SL TH TL TI<br />
Set of archwires MDB<br />
Wires required<br />
(please tick)<br />
straight indiv.<br />
lat. sec. lat. sec.<br />
12 Ø<br />
14 Ø<br />
16 Ø N<br />
16 Ø braided<br />
16 x 22 E E N<br />
18 x 25<br />
16 x 22 N<br />
16 x 24 E<br />
18 x 25<br />
18 x 25 (red.)<br />
17,5 x 17,5<br />
17 x 25<br />
18,2 x 18,2 E N<br />
18,2 x 25<br />
Please note:<br />
We always need one silicon impression for each arch that is to be bonded - for<br />
opposing arches a plaster model is sufficient. For details regarding impression taking<br />
or other detailed in<strong>form</strong>ation please look at our website www.lingualtechnik.de or<br />
contact us directly. If you only want us to position one arch, please nevertheless<br />
always indicate if you plan any treatment for the opposing arch - even if it is<br />
<strong>lab</strong>ial.<br />
TMA Steel SE Ni-Ti
Change language