Customize Your Appliance

Patient Name

Patient Phone
If there are questions regarding your appliance, we will contact you at this number.

Doctor Name

Comments
If you have a specific request for the customization of your appliance that does not include an image, please provide detailed instruction below. Please refer to the Orthotek Color Card to choose your colors.

Image
This image should be the exact representation of what will be placed on the appliance. No additional editing will be made. The minimum image width is 80 pixels. If the image provided does not comply with the specified size, we cannot guarantee the quality of the customization.