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QC Orthodontics Lab, Inc. 109 Spence Mille Road Fuquay-Varina, North Carolina 27526 800.537.1018 www.QCorthodontics.com In order to have a Milti-Loop Edgewise Arch Wire (MEAW) constructed, there should be no crowding, rotation or spacing in the dentition. The bracket slot size must be .018 inch and the molar tube size must be .018 x .025. Please fill out the information below and mail it with the plaster models to our lab by using the prepaid mailing label. Doctor: _____________________________________________ Telephone:_____________________________________ Address: ____________________________________________ Patient: _________________________ Age: _________ City: _______________________________________________ State: ___________________________ Zip: _________ Date Wanted: ________________________________________ Appointment Date: ______________________________ Patient:_____________________________________________ Age: __________________________________________ Please check all that apply: ❏ Class I ❏ Class II ❏ Class III ❏ Openbite? ____ mm. ❏ Overbite? ____ mm. ❏ Midline Shift? ____ mm. Construct MEAW: ❏ Upper ❏ Lower Tip-back Activation required: ❏ Upper 3 degrees ❏ 5 degrees ❏ none ❏ Lower 3 degrees ❏ 5 degrees ❏ none Brackets and tubes: ❏ Standard .18 inch slot How many degrees of torque in the brakcets and tubes? Upper central_____, lateral_____, canine_____, premolar_____, molar_____ Lower incisors_____, canines premolars_____, 1st molars_____, 2nd molars_____ Any special instructions?______________________________________________________________________________ __________________________________________________________________________________________________ Please indicate any tooth rotations, intrude or extrude adjustments on the diagram. Must be retained for two years. Doctor’s Signature License Number MX MD
