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Rx Date:
Pt. Sched Date:
Dr. Name:
License #:
Patient Name:
Dr. Address:
City: State: Zip:
Phone:
Tooth #(s):


 

Porcelain to Metal

Non-Precious (white)  
Noble (white)  
Hi-Noble (white)  
Hi-Noble (yellow)  
Captek (yellow)

Margin Design

Facial Porcelain butt-margin
360° Porcelain butt-margin
Show no facial metal (Traditional PFM)
360° Porcelain over metal margin
Metal margin 360°

 

Pontic Design

 

 

Metal Design

 

 

Return For

Die Trim
Metal try-in
Bisque
Finish

 

Full Cast Crowns

Non-precious (white)
Noble (white - Ag/Pd)
Noble (yellow - 20% Au)
Noble (yellow - 50% Au)
Hi-Noble (white - 65% Au)
Hi-Noble (yellow - 75% Au)
Hi-Noble (yellow - 86% Au)

 

All-Ceramics

Empress
Eris
Procera
Cercon

 

Composites - Provisionals

Cristobal
Targis / Vectris
Q-Temp Provisionals
Fiber / wire reinforcement

 

Insufficient Room?

Please call
Reduce/mark on opposing
Metal occlusal/lingual
Reduction coping

 

Occlusal Clearance

In occlusion
Slightly out of occlusion
Foil relief

 

Shade and Characterization

   

Notes:

Shade:
Stump Shade:

 

Instructions

Contour for future partial
Follow enclosed study model
Lab remake
Send Rx's & Shipping supplies
Call me before proceeding with case

 

Enclosed with Case

Impressions/Models
Bite
Shade
Photos

Notes:

 

 

 

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