Thermo-Splint RX

You may simply print out this form on your printer,
or fill it out on screen and then print out on your printer.
Today's Date

Doctor

Patient

Due date Please allow 4 working days in the lab.

Select type

Thermo-Splint® Hard Face

Thermo-Splint® Classic

Thermo-Splint® Custom Fit

Our standard splint is maxillary with canine guidance and a bite opening 1.5mm past the point of cusp interferences.

Select arch

Maxillary (standard)

Mandibular

Select design

Canine Guidance (standard)

Flat Plane
Other – for custom splints
Design or describe below

Authorized Signature

ID#
©2006 O’Brien Dental Lab, Inc. 4311 SW Research Way, Corvallis, OR 97333
(800) 445-5941 (541) 754-1238 fax (541) 754-7478

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