Bands Order Form
To order our bands please fill out the form below.
We will contact you soon for order confirmation and payment information.
Doctor's name
Address
E-mail
Telephone
FAX
Preferred brand
Possible brand replacement
Tube slot size
Facebow tube size
"A" Co.
Unitek
Ormco
G.A.C.
Dentaurum
American Orthodontics
Ortho Organizer
Forestadent
Lancer
T.P.
"A" Co.
Unitek
Ormco
G.A.C.
Dentaurum
American Orthodontics
Ortho Organizer
Forestadent
Lancer
T.P.
.018"
.022"
.045"
.051"
Triple
Double
Single
Maxilar
Lingual attachment
No Lingual
Lingual Cleats
Lingual Sheats
Lingual Button
First Molar Left
Size
Qty.
First Molar Right
Size
Qty.
Second Molar Left
Size
Qty.
Second Molar Right
Size
Qty.
Triple
Double
Single
Mandibular
Lingual attachment
No Lingual
Lingual Cleats
Lingual Button
First Molar Left
Size
Qty.
First Molar Right
Size
Qty.
Second Molar Left
Size
Qty.
Second Molar Right
Size
Qty.
Total of bands:
Comments: