Brackets and Tubes
(to place an order of bands click here!)
To order our brackets and tubes please fill out the form below.
We will contact you soon for order confirmation and payment information.
Doctor's Name:
Address:
E-mail:
Telephone:
Fax:
 
Brackets
Manufacturer & Line: Prescription:
Slot: Mini: Standard:
 
Hooks: Cuspids Bicuspids:  
  Hook/Power arm Ball hook Upper and/or Lower  
 
   
R 5 4 3 2 1 1 2 3 4 5 L
5 4 3 2 1 1 2 3 4 5
   
 
Comments:
Total of brackets:
 
Tubes
Manufacturer & Line: Prescription: Slot:
       
   
R 7 6 6 7 L
7 6 6 7
   
Comments:
Total of tubes: