™ ORDER ADDITIONAL INITIAL DEVICES (AS NEEDED) The MicrO2 Series includes 4 devices: Additional MicrO2 Initial (0) Device(s) Only 1 Set of Upper and Lower Initial Devices milled at (0) position (0) = Initial repositioning bite location Quantity AND q ATTN: ___________________________ ACCOUNT#: ________________________ Rx Date __________________ Due Date In-Office______________ FOR DELIVERY BY 5PM. NOTE: If no due date is assigned, a standard MicroDental due date will be applied. ____________________________ ______________________________ DR. NAME/ADDRESS PATIENT NAME (Please Print) q ____________________________ ______________________________ DR. PHONE PATIENT APPOINTMENT DATE ____________________________ SEX: M / F DR. EMAIL AGE: ______________ ____________________________ ______________________________ SIGNATURE OF DENTIST (Required) DENTIST LICENSE# Person signing this authorization accepts sole responsibility for payment and agrees to pay all legal and collection costs in the event of suit, including reasonable fees. Dentist’s signature will authorize MicroDental Laboratories to construct, alter or repair the restoration described on this requisition. INSTRUCTIONS ❍ CALL ME (BEFORE PROCEEDING WITH CASE) PLEASE SEND ______________________________________________________________ ❍ Sleep Rx’s ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ❍ Continuing Education Info ❍ Full Lab Service Info ❍ Shipping Boxes/Supplies ❍ UPS Airbills ❍ Sample Model ($415) ❍ George Gauge Kit ($65) ❍ George Gauge Forks 2mm ($2 per unit) Standard Series A 1 Upper Advancement Device milled at 1 mm 1 Lower Advancement Device milled at 2 mm Standard Series B 1 Upper Advancement Device milled at 1.5 mm 1 Lower Advancement Device milled at 2.5 mm q OR OR Custom Series 1 Upper Advancement Device milled at _______mm 1 Lower Advancement Device milled at _______mm ______________________________________________________________ MDL_140773_MicrO2 Rx 800.229.0936 · MicroDental.com ALL PRODUCTS MADE IN THE USA FOR LAB USE _____Please use new Repositioning Bite (Included) _____Please reset my patient’s digital file to reflect this new bite position (Included) ADDITIONAL ADVANCEMENT DEVICE(S), ONLY Please circle the Advancement Device(s) you require: Advancement is measured from (0) position (0) = Initial repositioning bite location Upper: –0.5 mm 0.5 mm 1 mm 1.5 mm 2 mm 2.5 mm 3 mm 3.5 mm 4 mm 4.5 mm 5 mm 5.5 mm Lower: –0.5 mm 0.5 mm 1 mm 1.5 mm 2 mm 2.5 mm 3 mm 3.5 mm 4 mm 4.5 mm 5 mm 5.5 mm Variations* Unusual Midline Deviations On occasion the lab may receive a bite that appears to be in cross-bite or have a midline deviation that is unintended. In the absence of verification, the lab will stop processes and call for verification. Please verify: Lower midline should be: ______ Aligned with Upper ______ mm(L) ______ mm(R) No ______ Yes ______ Please specify: ($2 per case) _____Please use Initial (0) Position (Bite on file) TO ASSIST THE LAB, PLEASE IDENTIFY: ______________________________________________________________ ($2 per unit) Advancement is measured from initial (0) position, on file: NOTE: 0.25 mm increments may be custom ordered ______________________________________________________________ ❍ Extra Carry Case ❍ George Gauge Forks 5mm Lower The MicrO2 Series gives you a total of 2 Upper Devices and 2 Lower Devices to offer you 3 different combinations of advancements. You can combine one of the (0) devices with either of the advancement devices, or combine the 2 advancement devices together to achieve maximum advancement. Additional Spacer Are there any loose teeth, periodontal issues, planned extractions, restorations, temporaries, fragile veneers, etc.? ______________________________________________________________ Upper ______________________________________ Partial or Fully Edentulous Will patient be wearing removable prostheses with their MicrO2? No ______ Yes______ MicrO2 STANDARD DESIGN: · lingual-less · upright posts · full occlusal coverage · flat occlusal planes · WITHOUT CLASPS Clasps, acrylic design changes, such as airway openings, lingual acrylic or deprogramming blocks, post inclination changes, hooks, or other design mechanisms, must be requested specifically, in the INSTRUCTIONS section of this Rx. *Additional service fees will apply. OUR PROMISE TO YOU: Upon incoming examination of your case, if the MicrO2 laboratory team determines that there is not enough bite clearance, nor enough retention to accommodate the standard design, we will NOT make changes without your knowledge or authorization. Our manufacturing processes will be temporarily stopped until we are able to contact you for a consultation regarding design alternatives that you prefer and prescribe. The MicrO2 is an FDA cleared and registered medical device. Warranty: MicroDental 100% guarantees the workmanship and materials of this device. MicroDental service warranty can be found at http://www.microdental.com/tandc/ Disclaimer: MicroDental Laboratory cannot warrant against customer dissatisfaction due to diagnosis, treatment decisions, style or brand of device chosen. We’re happy to assist you with any device adjustments and/or modifications, and to provide you with any information you may need to learn about the use of these devices. NOTE: Please use blue or black ink when completing this form. MicrO2 Sleep Device SELECT YOUR NEW MICRO 2 SERIES PLACE & TRACK YOUR ORDER ONLINE. TO REGISTER VISIT: http://mydentallab.microdental.com 5601 Arnold Road · Dublin, CA · 94568 p 800.229.0936 · f 925.828.0153
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