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Dr. Trim
Try-in
Finish

Fixed Prosthetic

Porcelain 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*

Implants

Implant Brand

Implant Platform Size

CAD Custom Abutment

Titanium
Ziconia Hybrid

Abutment Choice

Generic
Parent

Crown

Cementable
Screw Retained

Parts Enclosed

Impression Coping
Lab Analog
Abutment
Screw

Pontic Design

Shade

Final Shade

Stump Shade

Request Shade Consultation

May we do one of the following if necessary?

Reduction Coping

Yes
No

Reduce Opposing

Yes
No

Adjust Draw

Yes
No

Any future restorative plans?

Yes
No

Removable Prosthetics

Tooth Shade

Tissue Shade

Denture

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)

Lower Tooth Number (s)

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Fixed Prosthetic

Implants

Shade

May we do one of the following if necessary?

Removable Prosthetics

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