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


 

Select Classification

Premium (Bioblend IPN, Portrait, SLM teeth)
Standard (Ivoclar or Bioform IPN teeth)
Economy (stock plastic teeth)

We will select the brand of denture tooth based on
the shade guide you use, unless instructed otherwise.

 

Shade

 

Mould
Acrylic Shade
Light   Med   Ethnic

 

Full Dentures

Immediate (Extract tooth# )
Try-in
Finish
Ideal set-up
Characterized set-up

 

Cast Partial Frames

Frame only
Frame try-in w/rim
Frame try-in w/ teeth
Finish
Titanium frame

 

Flexible Partials/Clasps

Valplast
Valplast / cast combo
Acrylic partial
Try-in
Finish
Thermoflex clasp

 

Nightguards and Splints

Bruxguard
Bruxguard Plus
Soft nightguard
Processed acrylic splint
Athletic mouthguard
Snoreguard / DeSra

 

Instructions

Call me before starting case
Follow enclosed study model
Lab remake
Send Rx's & Shipping supp.

 

Notes


 

Partial Design - Upper

Horseshoe
Palatal strap
A-P strap
Full coverage
Lab design

 

Partial Design - Lower

Lingual bar
Lingual plate
Kennedy bar
Double bar
Lab design

 

Clasp Design

Lab design
RPI
Roach
Akers
Hidden Clasp

 

Clasp Type

Cast
Wire
Thermoflex

 

Enclosed with Case

Impressions/Models
Bite
Opposing
Shade/Mould

 

Notes

 

 

 

 

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