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4201 Sanderson Lane, Texarkana, AR. 71854
www.cusdela.com, Office: 870-779-9490
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
If an adjustment is need:
O Adjust Opposing
O Call the Office
Pontic Design
Zirconia
O 3D Pro Multilayer
O KATANA MultiLayer
O BruxZir
O Argen Hi-Strength
O PFZ (Zirconia on Lingual +
Porcelain on Buccal)
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 # : _______________________________________________________________________
Porcelain fused to Metal
O PFM Non-Precious
O PFM Semi-Precious White
O PFM High Noble-White
O PFM High Noble Yellow
O PFM buccal + Metal Lingual
O PFM buccal + Metal Occlusal
O Maryland Bridge Non-Precious
O Post & Core Non-Precious
O Post & Core Semi-Precious
Veneer
O IPS e.Max Press
O BruxZir Esthetic
O 3D Pro Esthetic