Splint Order Form


Please submit your case


If you have any questions, please call 866-695-3319 for assistance.

Doctor's Name *
Doctor's Name
Office Phone Number
Office Phone Number
Office Shipping Address
Office Shipping Address
Patient Name *
Patient Name
Type of impressions being sent to the lab for this case *
Always send both arches. Do not send plaster models Please include a wax bite and/or intra-oral photos.
Add on a duplicate backup splint for only $49.99 more?