CusDeLa

 Custom Dental Lab

4201 Sanderson Lane
Texarkana.AR. 71854
 
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 #  :  _______________________________________________________________________