Order Form

Doctor's Name :
Patient Name :
Phone :
Email Id :
Address for Communication :


Upper Arch Lower Arch
Extraction:            
Extraction:            
Non-Extraction:
Non-Extraction:
Proximal Stripping: 
Proximal Stripping: 
   
Molar Relation
Right:                         

Left:                           
Canine Relation
Right:                         

Left:                           
Expansion
Maxillary Arch:                  
 

Mandibular Arch:                
ARCH FORM  
Straight Mushroom
WIRES REQUIRED
Upper
014niti
016niti
WIRES REQUIRED
Lower
014niti
016niti
   
016x016niti
016x022niti
016x016niti
016x022niti
   
017x017niti
017x025 niti
017x017niti
017x025 niti
   
016X022 TMA
017X025 TMA
016X022 TMA
017X025 TMA
BRACKETS
Single Slot Bracket Dual Slot(only upper anterior) Bracket
Self Ligating Bracket
For any other requirment please specify

I Agree To The Terms & Conditions given below
All payment has to be done before the commencement of work.
Payment only by DD, cheque at par & account transfer in favour of ‘ Lingualmatrix’
Delivery time of about 3 weeks from the time we receive the models / impression in good condition.
ARCH WIRES - ANY 4 ARCH WIRES WILL BE   PROVIDED WITH EACH CASE.
EXTRA ARCH WIRES - INR 500/- EACH

 

 

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Contact Us

Laxmi Niwas, 1st Floor 18th Road, Near. FAB India, Khar(W), Mumbai - 400 052. INDIA.
9892310989 / 022 26059987