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Band Refills Order Form

Please read before you fill:
  1. Plain bands or bands with upper Double Headgear and Lower Single Tubes are standard and can be orderd in any quantity in multipules of 5pc. Minimum order is 5pc.
  2. For any other combination of tubes or bands with lingual attachments the order should be for minimum of 200pc total and would be considered a custom order.
  3. All Custom orders will take 3-4 weeks for delivery. Custom orders can not be cancelled and are not returnable.
Maxillary 1st Molar
Buccle TubeLingual AttachmentPrescriptionSlot
Single Sheath Roth .018"
Double Head Gear Cleat MBT .022"
Double Auxillary Not Required    
Triple      
SizeURUL SizeURUL SizeURUL SizeURUL
29 29.5 30 30.5
31 31.5 32 32.5
33 33.5 34 34.5
35 35.5 36 36.5
37 37.5 38 38.5
39 39.5 40 40.5
41 41.5 42 42.5
43 43.5 Total Upper Bands
Mandibular 1st Molar
Buccle TubeLingual AttachmentPrescriptionSlot
Single Sheath Roth .018"
Double Auxillary Cleat MBT .022"
Double Lip-bumper Not Required    
       
SizeLRLL SizeLRLL SizeLRLL SizeLRLL
29 29.5 30 30.5
31 31.5 32 32.5
33 33.5 34 34.5
35 35.5 36 36.5
37 37.5 38 38.5
39 39.5 40 40.5
41 41.5 42 42.5
43 43.5 Total Lower Bands

If your order exceeds 400pc we will ship it packed in band tray. For orders less than 400pc, zip-lock bags will be used for packaging. If you need a tray for such orders, the tray cost would be additional $10. Please tick below if you need it.

I need band tray at additional cost       Price for tray + $10.00

Maxillary 1st Molar
ItemParticularsTotalPriceAmount
Molar Band Upper 0.65 65
Buccle Tuble
Lingual Attachment
Mandibular 1st Molar
ItemParticularsTotalPriceAmount
Molar Band Lower 0.65 65
Buccle Tuble
Lingual Attachment
Total | $0  
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