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Appliances
Merlin Dental Laboratory, Inc.
Information
Online Order Form
*note:
this is an unsecure email form, if you are uncomfortable
submitting the following information, please print this page
and either fax it to us, or mail via US Postal Service to our office.
Name:
Phone Number:
Email:
Address:
City:
State:
Zip Code:
Patient
Name:
Patient Age:
Date Case Sent:
Patient Scheduled At:
AM/PM Date:
TMJ Splint
Conditions
Bruxism
Headaches
TMJ Dysfunction
Type of Splint
Upper
Lower
Full Coverage Flat Plane
Poseterior Occlusion Only
(canines covered)
Indexing
Flat
Medium
Maximum
Gnathologic
(incisal guidance)
MADD
(anterior disclusion device)
Other
(describe below)
Airway Dilator Appliance
Diagnosis
Snoring
Sleep Apnea
UARS
Periodic Limb Movement Syndrome
Appliance
EMA® I Custom
EMA® I Professional
EMA® II Custom
EMA® II Professional
Silencer® Titanium
Silencer® Titanium Heavy Duty
Oasys® Oral/Nasal Airway System
(describe below)
