Prescription

(888) 242-7460

Urbanek Providers- Order Device

US Pat. No. 9314320

TMJ Services Lab Prescription

8119 Isabella Lane, Ste 108

Brentwood, TN 37027

Please pay lab fee and print shipping label. If this is a remake, or if your case will require teeth added, please call our office to place your order at (888) 242-7460 and ask for Naomi.

** To upload a scan, scroll down to the black box that says, " Upload scan" and follow prompts. You can do this before or after paying.

Doctor's Name

Date

Address

Patient's Name

Office Location

RX: Special Instructions

License #

I agree to the Terms & Conditions

Need Shipping Label- (A label will be emailed to email address provided if box is checked).

Description of Patient Symptoms

If you have made prior payment arrangements, click on "Submit Prescription" and simply exit when you see the payment page. If not, proceed with entering payment info after clicking "Submit". Please enter Phone Number if you have questions.

Prefer to pay later?

Pay Later (DSO practices only)

UPLOAD SCAN

TO SEND SCANS ATTACHED TO PRESCRIPTION, SAVE YOUR SCAN AS AN STL FILE BY CLICKING ON THE GREEN BUTTON BELOW. **Make certain the scan is saved as patients first name and last initial, followed by the Providers last name. Eample: (Jennifer D, Dr. Smith)

UPLOAD STL FILE SCAN HERE

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Urbanek Device and Protocol
8119 Isabella Lane Suite 108,
Brentwood, TN 37027
(888) 242-7460

Contact

(888) 242-7460

Urbanek Providers- Order Device

UPLOAD SCAN

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