QC Orthodontics Lab, Inc.
109 Spence Mill Road
Fuquay Varina, NC 27526
(800) 537-1018 (919) 577-2250 (919) 577-2253 (fax)
www.qcortho.com [email protected]
FIXED APPLIANCE PRESCRIPTION
Doctor ____________________________
Telephone ______________________
Address ___________________________
Patient _________________________
email __________
Age ___________
City _______________________________
State___________________________
Zip ___________
Date Wanted
SPACE MAINTENANCE & REGAINERS
DISTALIZATON
EXPANSION AND ARCH DEVELOPMENT
RPE
Bonded RPE
Debonding Loop
Max
Mand
Stealth Compact RPE
Unilateral
Expider
Add Expansion
HAAS Palatal Expander
Williams
Bilateral
Bonded EZ Distalizer
Max
Mand
Snaplock RPE
Max
Unilateral
Mand
Bilateral
Add Expansion
Anatomical Expansion Screw
Pin Tube with Extensions
E-Arch
Greenfield
Unilateral
Soldered Quad Helix
Snodgrass
Soldered Quad Helix w/Extensions
Hilgers Pendulum
Dillingham I
Bilateral
Hilgers T-Rex Pendex
Hilgers Tracey Mini Distalizer
Nitanium Expander
Back Action Bite Plate
Ron Bell Appliance (2 Springs)
IPC Molar Distalizer
Mand
Max
Soldered “W” Arch
Max
Sagittal
Unilateral
Mand
Two Way
Three Way
Molar Distalizing
Adjustable Loop Lingual Arch
Lip Bumper with Acrylic Pad
Bilateral
IPC CD Distalizer
Max
Mand
One Way
6X6 Lingual Arch with Loops
Mixed Dentition Lingual
Removable Lingual Arch
3D Lingual Arch
Class II Lingual Arch
Class III Lingual Arch
Band and Loop
Band and “L”
Please Call Concerning Case
HABIT APPLIANCES
Spring Loaded Band and Loop
Molar Roller
QCK Appliance
Appointment Date
6X6 Lingual Arch
EZ Distalizer
Unilateral
Bilateral
EZ Pliers
IPC Activation Tool
Extra Spacers (8)
Halterman Appliance
Ectopic Spring Loaded Distalizer
Distal Shoe
Retainer with Pontic
Fixed Transpalatal Arch
Removable Transpalatal Arch
Removable TMA Transpalatal Arch
Tads Transpalatal Arch
Nance Button
Texas Nance Button
Wire Nance
Tongue Habit (mandibular)
Hay Rake
Bluegrass (roller)
Bluegrass (beads)
Quad Helix with Habit (standard)
Quad Helix with Habit (aggressive)
Dillingham Habit (no expansion)
Rib Cage Thumb Habit
Stealth Expanding Habit Appliance
Add Spikes
Seat Doctor’s Bands
Seat Lab Bands
Crowns
Bi Helix
DOCTOR’S COMMENTS
PONTICS AND PARTIALS
Pediatric Partial
Number of Teeth
Groper Pediatric Partial
Number of Teeth
Flipper
Shade _____________
Doctor’s Signature
Tongue Habit (maxillary) (vertical
Reseat Doctor’s Bands
Hamula
VECS RPE
Cetlin Appliance
ACCO Appliance
Thumb Habit (conformed to palate)
License Number
For Improved Accuracy Identify Appliances by Appliance Codes found on Price Sheet or Website