RX Form

Download our prescription form and include it with every case.

Type into the fillable version on your computer, or print the blank version and fill it in by hand.

Fillable PDF
Type into the form on your computer, then save it.
Download fillable RX formPDF, 1 page, Letter size
Printable PDF
Print a blank copy and fill it in by hand.
Download printable RX formPDF, 1 page, Letter size

Sending the form with your case

Digital cases: add the completed form as an RX file on the Submit a Case page.
Physical cases: include the printed form with the case.
Questions about a prescription? Call (604) 873-1613.

Preview of the Good Year RX form: doctor, patient and date lines, upper and lower tooth charts, Rx lines, shade box, and metal, occlusion, margin, zirconia and pontic design options.