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Rx ONLINE FORM

Submitting your dental cases has never been easier. Our Rx Online Form is a secure, streamlined solution for dentists and orthodontists to upload prescriptions, case details, and supporting documents directly to our lab.

Rx FORM

Dr
Email
Phone
Order Date
Patient Name
Patient Age
Delivery Date
Delivery Time
Delivery Address
Upper Teeth
Lower Teeth
Instruction
Office Use Only
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Rec'd
Prep
Packed
Q/C
Please Specify Required
Margin Adaptation Required
Centric Contact Required
Labial Margin Required
Lateral Excursion Required
Pontic Design
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Hygenic-gray_edited.png
Cone-gray.png
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Contact (Embrassures)
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Normal-gray.png
Point-gray.png
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Special Shade Selection
Electronic signature

Thanks for submitting!

Orthodent Ltd.

92 Bowers Ave

Runnemede NJ

08078

Your Full-Service Dental Laboratory
Specializing in Orthodontics

Serving North America Since 1988

HOURS

Monday: 8:30am - 5pm

Tuesday: 8:30am - 5pm

Wednesday: 8:30am - 5pm

Thursday: 8:30am - 5pm

Friday: 8:30am - 5pm

Saturday & Sunday: Closed

CONTACT US

Phone: 1 (856) 939-5666
Fax:
1 856 939-5669

Email : info@orthodent.ca

Leadership • Bill Van Evans   |   Our Commitment   |   About Us

Accessibility   |   Warranty   |   Forms   |   Brands   |   Careers

ORTHODENT US LTD. © 2025  ·  ALL RIGHTS RESERVED
Designed By: Alero ®

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