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Prepare your prescription

Orthodontic 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.

Orthodontic 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

03

Case handling

Requests
Please send
04

Removable appliances

Hawley
Spring retainers
Vacuform
Speedaligner
Sagittal
Expansion
Bionator options
Other removable appliances
05

Fixed appliances

CD Distalizer
CD Advancer
Controlled Arch: arch development
Additional arch development
A-P / orthopedic correction
EZ Bond Retainer
Indirect Lingual Retainer: arch
Additional retention / anchorage
Bracketing: Controlled Arch
Bracketing: Bands
Bracketing: Brackets only
Bracketing: Brackets in matrix
Flat Bite Plane
06

TMJ & sleep appliances

TMJ splint arch
TMJ splints
Snoring / sleep apnea
07

Records, colors & case instructions

Some lower arches and fixed appliances may require simplified acrylic designs. Return all models and appliances for remakes, repairs or credit evaluations.

Record models
Ceph tracing requested with this case

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