Lab Slip – Upload Files ContactDoctor Name* First Last Customer ID#Email* PhoneShipping Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code YOU MUST CHOOSE ONE (1) HARDWARE AND ONE (1) LINERPlease call with questions BEFORE ordering or an additional charge may be added for error in selection.TAP Hardware - Choose One dreamTAP* TAP 3* TAP 3 Elite TAP 1 All TAP Appliances are Medicare coded (E0486). dreamTap and TAP 3 Appliances can be fabricated to meet Medicare requirements. Please check this box if your appliance needs to meet Medicare requirements. If you have any questions, please call Airway Labs customer service at 866.264.7667 COMMENTSTAP Liner - Choose One Triple Laminate (TL) - Recommended ThermAcryl - Requires chair side heating REWORK/REMAKE Reset Hardware Remake Trays (keep hardware) Bite Index*Include Bite Index.No Bite Index.File Upload* Drop files here or Accepted file types: stl. Accepted file types: .stlAcknowledgement* I acknowledge that each file name must contain a reference number (i.e. initials, patient ID) or case may be delayed. ShippingShipping (Airway Management will ship UPS Ground unless otherwise specified below) Ground 2 Day Overnight If scheduled, please provide patient’s appointment date and time:Date Time : HH MM AM PM Comments / InstructionsDentist Signature:*Prices are subject to change.Dentist License #:*Rev. A, 2016EmailThis field is for validation purposes and should be left unchanged.