Submit A Case Download printable RX 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 Restoration Type **Full ZirconiaLayered ZirconiaEmaxLayered EmaxPFMFull Cast CrownTooth Numbers*ShadeFinal Shade*Stump Shade Request Shade Consultation Enclosed with Case Impression Digital Impression Bite Study Model Photo (via Email) Old Crown Ramitec ImplantsImplant BrandImplant Platform SizeCrown Cementable Screw Retained Parts Enclosed Impression Coping Lab Analog Abutment Screw May we do one of the following if necessary?Reduction CopingYesNoReduce OpposingYesNoAdjust DrawYesNoSpecial InstructionsUpload File Drop files here or Accepted file types: stl, pdf, jpg, png, gif, tiff, jpeg. Doctor's Name*Authorization* I authorize VIP Dental Lab to begin work. NameThis field is for validation purposes and should be left unchanged. VIP Dental Lab 9400 Middlebelt Rd Livonia, MI 48150 Tel. 734-525-8959 Office@vipdenatllab.com Schedule a Pickup