Teeth-N-Stuff

Dental Prosthetic Solutions
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Online Rx

To help expedite your patient's case, you may fill out my on-line form below. You may also choose a more traditional way by downloading and printing a copy of my prescription form and faxing it to me.

Rx Form (.pdf) (Adobe® Acrobat® Reader required; free download at www.adobe.com)

Patient Information
 

   
First Name Last Name  
 
Address   Phone Number (xxx-xxx-xxxx)
City State Zip Code
Age    
Male Female  

Doctor's Information
 
   
First Name Last Name Name of Office Contact
Address   Phone Number (xxx-xxx-xxxx)
City State Zip Code
License Number

Appointment Type Case Type  
Try-In
Finish

(ctrl+click for multiple selections)

     
Appointment Date Appointment Time  
     
Shade Code Please call doctor  
   
     
Instructions    

 

  © 2004 Steve Geib