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Rx Sheets

The following Rx Sheets can be downloaded from our website. You will need Adobe Acrobat to open/print the documents.

Note: If you are requesting an appliance be made from a digital model, please complete an Rx for the appliance of your choice. Also, there is a laboratory fee of $8.50 per arch for printing a model to fabricate an appliance.

Law requires that our customers sign each Prescription Rx and include a valid license number. You may sign these digitally by typing your name after the digital notation "/s/" on our prescription forms.

Example e-Signature: /s/ Dr. John Doe

Complete an Electronic Rx Sheet

For security purposes, we request that all electronic Rx Sheets be sent to us through our secure case uploader. Download the form below, save it to your computer, complete and sign it electronically (including license number), and upload to our digital uploader.

If you have any questions, please contact us at digital@specialtyappliances.com or call 1-800-522-4636 to speak with a customer service representative immediately.

* Click here to obtain the free Adobe Acrobat reader.