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4201 Sanderson Lane, Texarkana, AR. 71854
www.cusdela.com, Office: 870-779-9490
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Doctor's Name_________________________________________________
Address ________________________________________________________
City ____________________________ State _________ Zip ___________
Phone ________________________ Email __________________________
Patient Name ___________________________________________
Date of RX _____________________________________________
Return Date ____________________________________________
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4201 Sanderson Ln, Texarkana. AR. 71854
www.cusdela.com Office: (870)779-9490
REMOVABLE RESTORATIONS
O Upper O Lower O Try-in O Finish O Cusil Style
Check all that apply
O Denture O Immediate/Surgical Denture O Bite Block
(Try-in required for cases with open end saddle or missing more than 6 teeth or warranty is void).
Extraction Tooth # ____________ O Extract All O Extract now O Extract after Try-in
Flexible Partials
O Flexible Partial
O Flexible Unilateral. (Maximum 2 Teeth)
O Flex + Cast Frame, Combo
O Flex + Vitallium 2000+, Combo
Acrylic Partials
O Cast Frame w/Acrylic
O Vitallium 2000+ w/Acrylic
O Clear Frame w/Acrylic
O Flipper (1 tooth all Acrylic)
O Acrylic Partial (No frame)
(wrought wire Clasps)
Flexible Shade
O Light Pink
O Pink
O Medium Meharry
O Dark Meharry
Acrylic Shade
O Pink
O Light Pink
O Light Meharry
O Medium Meharry
O Dark Meharry
O Lucitone 199
Clasp Type
O Cast * O Wire *
O Flexible O Clear *
(Can NOT combine Clear clasp with Flex)
Design
O Full Palatal Metal Coverage
O Metal Occlusion
O Lingual Bar
O AP Open Palate
O Horseshoe Palate
O Palatal Strap
O Rest
O Lingual Apron
O Precision Attachments*
Lucitone Denture
O Original
O Light Pink
O Light Reddish Pink
O Dark Reddish Pink
O Original Opaque
Tooth Shade _______________________
Teeth O Stock (Included)
O IPN Portrait *
O old open Face *
O Full Gold
* Additional Charge
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Reinforcement
O Wire* O Mesh*
Valplast Partials
O Valplast
O Valplast Cast Combo
O Valplast Vitallium 2000+ Combo
Metal Frameworks
O Cast framework Only
O Vitallium 2000+ Framework Only
Night Guards / Bite Splints (Upper unless specified)
O Hard
O Soft
O Hard/Soft 2mm
O Hard/Soft 3mm
O Surgical Stent
Attachments* O Harder Bar O ERA O PD O Other ____________
Repair and others
O Basic Repair
O Reline
O Rebase
O Soft Liner
O Add Tooth # ______________
O Patient Name on Denture
O Duplicate Model
O Custom Tray
O Base Plate/Bite Rim
Clear Frameworks
O Frameworks only
Doctor Signature .........................................................................................
License ........................................................................................................
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