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Rx Sheets

The following Rx Sheets can be downloaded from our website. You will need save the PDF document to your computer and then open in Adobe Acrobat or Reader to open/print the documents.

We recommend that you obtain the most recent version of the FREE Adobe Reader to use these forms.

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 for printing a model to fabricate an appliance.




Specialty Rx Form Overview


In our commitment for continuous improvement, we have updated our prescription forms in order to make them easy to follow and consistent with all our product lines. Whether you are ordering our M4™ MiniScope® Herbst, Clear Image® Aligners, GUARDIAN® Retainers, or one of our many other products, all ordering will be done using this easy to follow template.


Signature, License and Expiration Requirements


As of January 1, 2015, we require that our customers sign each Prescription Rx and include a valid license number and expiration date. You may sign these digitally by typing your name after the recognized notation "/s/" for digital signatures on our prescription forms.

Example e-Signature: /s/ Dr. John Doe, GA4905, exp 12/2016





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 signature, license number and expiration), and upload to our digital uploader.

We recommend that you obtain the most recent version of the FREE Adobe Reader to use these forms.


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.