Fixed Restorations Rx Form | CusDeLa dental lab

CusDeLa

Custom Dental Lab

4201 Sanderson Lane
Texarkana.AR. 71854
www.cusdela.com
Office:(870) 779-9490

Doctor's Name__________________
Address
City _ State _ Zip _
Phone _ Email ________

Patient Name______________________
Date of RX _
Return Date ________________________

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FIXED RESTORATIONS

Shade Instructions:

Shade _

Stump Shade _

Full Metal Cast
O Non-Precious
O Semi-Precious White
O Semi-Precious Yellow
O High-Noble White
O High-Noble Yellow
O NP Post & Core
O SP Post & Core

If an adjustment is need:
O Adjust Opposing
O Call the Office

PFM
O Non-Precious
O Semi-Precious
O High Noble White
O High Noble Yellow
O Porcelain Butt Margin

Pontic Design

Zirconia
O KATANA MultiLayer
O BruxZir
O Argen Hi-Strength
O PFZ (Porcelain Fuse to Zirconia)

IPS e.Max
O e.Max Pressing

Occlusal Staining:    O   None O Light O Medium O Dark
Occlusal Contact: O   Light    O Open O Tight
Contact & Embrasures: O   Broad O Light O Tight

Temporary, PMMA O Shaded O Multi Layers

Restoration O Inlay / Onlay O Veneer O Crown O Bridge

Implant Abutments :

O. Stock Brand___________________________

O. Abutment material Choice:

a/ Titanium Custom Milled _____________________

c/ Zirconia ( Ti - Hybrid) _________________________

e/ Screw Retained_______________________

O. Emergence with options:

a/ Full Anatomical dimensions _________________

b/ Contour follow soft Tissue ___________________

c/ Support soft Tissue ___________________________

d/No Tissue displacement ______________________

Rx * Please provide any photos and study model on all Anterior.

Special Instructions:

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Dentist Signature: ______________________________________________________________

License # : _______________________________________________________________________

CusDeLa Custom Dental Lab 4201 Sanderson Lane Texarkana.AR. 71854 www.cusdela.com Office:(870) 779-9490

Doctor's Name______________________________________________ Address ____________________________________________________ City _____________________________ State _______ Zip _________ Phone _______________________ Email ________________________

Patient Name______________________________________________ Date of RX _________________________________________________ Return Date ________________________________________________

========================================================================================================================

FIXED RESTORATIONS

Shade Instructions:

Shade _____________ Stump Shade _____________

Full Metal Cast O Non-Precious O Semi-Precious White O Semi-Precious Yellow O High-Noble White O High-Noble Yellow O NP Post & Core O SP Post & Core

If an adjustment is need: O Adjust Opposing O Call the Office

PFM O Non-Precious O Semi-Precious O High Noble White O High Noble Yellow O Porcelain Butt Margin