Submit A Case Requested Date* Date Format: MM slash DD slash YYYY Doctor*Doctor's Office Email* Doctor's Phone*Doctor's Office Address*City*State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code*Patient's Name* First Last Patient's Sex*MaleFemale* Dr. Trim Try-in Finish Fixed ProstheticPorcelain Fused to Metal High Noble Noble Porcelain To Margin Porcelain Shoulder Lingual Collar Buccal Collor Lingual Collar MM*Buccal Collar MM*Full Cast Crowns High Noble (Yellow) Noble (White) Noble (Rose Gold) Metal Free Full Zirconia Full Ziexonia Translucent (up to 3 units) PFZ (Porcelain fused to Zirconia) E.max (Monolihic Crowns, Veneers, Inlays PFe.max (Porcelain to e.max high estetic) Enclosed with Case Impression Digital Impression Bite Study Model Photo (via Email) Old Crown Ramitec Diagnostics Dublication White Wax-up Suck Down Putty White Wax-up Number*Provisionals PMMA (Long Term Temp) Abutment Pontic Abutment Number*Pontic Number*ImplantsImplant BrandImplant Platform SizeCAD Custom Abutment Titanium Ziconia Hybrid Abutment Choice Generic Parent Crown Cementable Screw Retained Parts Enclosed Impression Coping Lab Analog Abutment Screw Pontic Design A B C D E ShadeFinal ShadeStump Shade Request Shade Consultation May we do one of the following if necessary?Reduction CopingYesNoReduce OpposingYesNoAdjust DrawYesNoAny future restorative plans?YesNoRemovable ProstheticsTooth ShadeTissue ShadeDenture Upper Lower Custom Tray Setup Finish Partials Metal Frame Try-in Metal Frame with Setup Metal Frame with Bite Rim Duraflex Partial Valplast Partial Unilateral Fle Par Acrylic Partial Flipper Wire Reinforcement Clasps Ball Adams C-Clasp Soldered C-Clasp Clear/Pink Repairs Reline Add/Reattach Tooth Add/Reattach Clasp Fracture Implant Prosthetics Insertion Jig Locator Implant Overdenture Milled Bar Overdenture Screw Retained Hybrid Overdenture Tooth Guard Upper Lower Nightguard Hard Nightguard Hard/Soft Athletic Guard Gel Bite Appliance Cuspit Rise Flat Plain Bite Splint For all other Ortho Appliances, please call the lab.Ortho Appliance Upper Lower Clear Ortho Retainer Other Upper Tooth Number (s) Select All 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Lower Tooth Number (s) Select All 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Special Instructions*Upload File Drop files here or Accepted file types: stl, pdf, jpg, png, gif, tiff, jpeg. Doctor's Name*Doctor's Signature*By signing, you agree that VIP Dental Lab will start work.CommentsThis field is for validation purposes and should be left unchanged. Download Form VIP Dental Lab 9400 Middlebelt RoadLivonia, MI 48150 Hours M-F 9am to 5pm 734-525-8959 734-525-8953 Schedule A Pickup