RX Change Request Invoice # (if applicable): Doctor Name: Patient Name: Doctor Email: Phone Number: Remake Reason (if applicable): Requested Return Date: Remake Instructions: Photos: *If the attachement is too large, please send photos via email to: photos@maverickdental.com. Please make email subject “RX Change Request Photos” Signature: Prescription has been reviewed for accuracy, legibility, and completion. Impressions have been approved by the Doctor.