KELLER LABORATORIES, INC.
Please send:
Today’s Date: ______________________________
Prescriptions
Boxes
Case Bags
160 Larkin Williams Industrial Court
Pre-paid Fed Ex Labels
Pre-paid Mail Labels
Fenton, MO 63026
Mailing Labels:
Return by 5:00 pm on: ______________________
636-600-4200 • 800-325-3056
Please allow 2 weeks from date case leaves your office
Please have a technician call me:
Yes (will delay case)
No
Email photos to
To Discuss:______________________________________________________
_______________________________________________________________
SPECIALTY APPLIANCE PRESCRIPTION
PHONE: (______)____________________________________________
DOCTOR:
PATIENT:
FAX: (_______)______________________________________________
STREET:
CITY:
STATE:
ZIP:
EMAIL:
Doctor Signature: ______________________________________________________ License No.: _____________________________________
NTI-tss Plus
TM
FULL COVERAGE GUARDS
2.
1. Choose the appliance:
Choose the lower arch
Choose the upper arch
1. Choose the appliance:
if your patient has:
if your patient has:
NTI-tss Plus
TM
Nighttime (Most prescribed design)
Crystal Clear ® (Hard, durable, non-porous,
Missing Lower Incisor
> 60% Overbite
NTI-tss Plus
Daytime (Daytime clenching only)
TM
Lower Veneers
> 4mm Overjet
injection-molded)
NTI-tss Plus
Soft (Extends 2nd bi - 2nd bi)
TM
Severe Class III Bite
Upper Veneers
ThermoFit ® (Hard, becomes flexible in hot water)
Uneven Lower Incisal Plane
Uneven Upper Incisal Plane
NTI-tss Plus
TM
Night & Day Set (NTI-tss Plus
TM
& NTI-tss Plus
TM
Daytime)
Upper Diastema
Comfort H/S
Bite Splint
TM
(Soft inner layer, hard outer layer)
NTI-tss Plus
TM
Universal Therapy Set (NTI-tss Plus
TM
& Opposing Universal Slider)
Lower (lab default)
Upper
2. Choose the arch:
Extend coverage from tooth # ________ to tooth # ________
Upper (lab default)
Lower
3. Measurements:
Okay to switch arches due to arch selection contraindications?
3. Choose the guard design*:
Maximum Protrusive Measurement __________mm
Yes
No, call first
Anterior Guidance (Ramp)
Simple Steps to a Maximum Protrusive Measurement:
• Instruct the patient to protrude their mandible as far as possible. Use a ruler to
Okay to extend if necessary to ensure adequate retention?
($20 fee for Comfort H/S with Anterior Guidance)
measure from the labio-incisal of upper centrals to lingual-incisal of lower incisors.
Group Function (No ramp)
Yes
No, call first
Daytime - No anterior coverage
Enclose VPS impressions or full arch models
* Specialty Designs Available
Enclose VPS impressions or full arch models.
SLEEP APNEA/ANTI-SNORING DEVICE
Send open bite with 2mm posterior clearance.
ClearDream
®
: Dorsal appliance with 5.5mm adjustable range.
Specify Design
:
(for TAP only)
ClearDream
with soft liner: Soft liner becomes flexible in hot water.
®
Triple Laminate (lab default)
VACUUM-FORMED APPLIANCES
ClearDream requires George Gauge bite or ClearDream bite technique (Call or go to for instructions)
ThermAcryl
1. Choose the
2. Choose
TAP
3 Elite: Anterior mechanism allows 10mm range & full lateral range of motion. Indicated for bruxers.
®
appliance:
the arch:
TAP
®
3: Anterior mechanism allows 5mm protrusion in 1/4mm increments.
Bleaching trays
Upper
EMA
: Elastic Mandibular Advancement. Posterior stops slightly increase VDO.
®
All Soft Night Guard (ProForm)
Maximum Protrusive Measurement __________mm (TAP Only)
Lower
Invisible Retainers
Send Full Upper and Lower VPS Impressions and Maximum Protrusive Measurement
Comments: ___________________________________________________________________________________________________________________________________________
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