Order Now: Tel 1-519-658-2925 • Fax 1-519-658-6925 • www.speedsystem.com • speedback@speedsystem.com | 35 SPEED System™ Orthodontics Fax Order Form Date: ___________ PO No.: _____________ Name: ______________________________ Address: ____________________________ City: ________________________________ Prov/State: __________________________ Country: ________ PC/Zip: _____________ Telephone: __________________________ Fax: ________________________________ E-mail: ______________________________ EI #: ________________________________ Order Placed by: ______________________ Order Verification:_____________________ Date Issued 8/27/98 Page 1 of 1 S-65 Revision O Last Revised 5/9/17 4 Lower Right (+) 1 Upper Right (-) SPEED Brackets SPEED Brackets SPEED Buccal / Convertible Tubes SPEED Buccal / Convertible Tubes 3 Lower Left (-) 2 Upper Left (+) LR1- ________ LR2- ________ LR3- ________ LR4- ________ LR5- ________ LR6- ______ LR7- ______ UR1- _________ UR2- _________ UR3- _________ UR4- _________ UR5- _________ UR6- __ UR7- ______ LL1- ________ LL2- ________ LL3- ________ LL4- ________ LL5- ________ LL6- ______ LL7- ______ UL1- _________ UL2- _________ UL3- _________ UL4- _________ UL5- _________ UL6- __ UL7- _______ M M M M M M M M M M M M M M M M M M M M M M M M ST ST ST ST ST ST ST ST DT DT Mini Mini DT DT CT CT CT CT CT CT CT CT Y Y Y -10˚ -10˚ -28˚ -24˚ N N N Offset: Offset: Offset: Torque: Torque: M M M M Large Pad Large Pad Large Pad Large Pad Large Pad Large Pad Large Pad Large Pad ERX Pad ERX Pad ER Pad ER Pad LR7- _____ UR7- _____ LR6- _____ UR6- _____ LL7- _____ UL7- _____ LL6- _____ UL6- _____ ____ Kit(s): ❒ 7-7 ❒ 6-6 ❒ 5-5 Hook Length: Small ❒ Medium ❒ Large ❒ Hook Size: ____________ (Example .019” x .025”) ❒ Regular ❒ Tubular ❒ Master Kit ❒ Upper 6 ❒ Upper 7 ❒ Upper 6 for Class II Correction ❒ Lower 6 ❒ Lower 7 Torque Prescription: As Per Previous Order: ❒ Medium ❒ High ❒ .018 ❒ .022 ❒ Yes ❒ No Slot Size: ❒ Hanson ❒ Regular SPEED Introductory Kit ❒ Trillium Compression Hook Kit SPEED Supercable Kits Convertible Tube Kits 11 12 13 14 15 16 17 41 42 43 44 45 46 47 21 22 23 24 25 26 27 31 32 33 34 35 36 37 Hespeler Orthodontics | Order Form Order Form
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