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14643 W. 95th StreetLenexa, KS [email protected]
Indirect Bonding
Instructions / Comments_______________________________________
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_______________________________________________________Doctor Telephone
Address
City State Zip
Patient’s Name
(Please request at least 1 business day prior to patient appt.)
Date Wanted
_________________
___________________
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_______________________________________________________Email
MidLyne™ Provided Brackets(Bracket System Preference) _______________
Tray Selection Full ArchMidline SectionTriple Tray
Dr. Provided Brackets .018.022
3-3 Composite Retainer
Bracket Placement: Please Specify mm From Incisal Edge In Tooth Spaces Above
