R

14643 W. 95th StreetLenexa, KS 66215913.492.4843800.287.5215info@midlyne.comwww.midlyne.com

Indirect Bonding

Instructions / Comments_______________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________Doctor Telephone

Address

City State Zip

Patient’s Name

(Please request at least 1 business day prior to patient appt.)

Date Wanted

_________________

___________________

_______________________________________________________

_______________________________________________________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