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Prepare your prescription

Ceph Tracing Rx

Fill in your case details, review them on screen, then print and sign.

Entries are not submitted to Johns Dental or saved by this site. Clear the form when finished.

Prefer the original PDF? Open it here

Browser adaptation of the published paper prescription. Review the original for its full instructions, diagrams and account terms. This draft has not been approved or submitted by the lab.

1 Complete form2 Review & print

Fields marked are required. Choose only the options prescribed for this case.

Ceph Tracing Rx details
01

Practice & timing

Choose a date wanted at least one day before the appointment. Weekends, holidays and transit days are not production days. Confirm timing with the lab.

Practice details
02

Patient details

The source form requires patient demographics, birth date and the date the X-ray was taken to complete the tracing.

03

Cephalometric tracings

Select an analysis or name another below. The source asks for teeth in occlusion, lips at rest, clear landmarks and a clear soft-tissue image. Image quality affects the tracing. No X-rays are uploaded here.

Analysis requested
04

Special handling

Requests
Please send
05

Records accompanying the case

These selections describe records you will provide through the lab’s normal case process. This form does not upload or send them.

Models and records enclosed
X-rays sent under separate cover
Previously supplied to Johns Dental
06

Tracing options & model analysis

Options marked “additional billing” carry that designation on the original prescription. Confirm current charges with the lab.

Output and record options
Model analysis

Reviewing does not send or approve the prescription. The prescribing dentist must check it and sign the printed copy before using the lab’s normal case process.

Clear this form?

Every entry will be removed. This cannot be undone.

ClearBow retainer

ClearBow retainer with Adams clasps