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Online RX Prescription Form Prescription Form * indicates required field. Personal Detail *Rx Date: *Due Date: *Doctor Name: *Doctor Address1: *Doctor Address2: *Doctor Phone: *Patient Name: Patient Sex: Male Female *Patient Age: Characterization Chart Shade: Stump: Value High(bright) Medium Low   Fixed  Porcelain-To-Metal/Full Gold Semi-Prec N CBY50 White Prec HN Premium Yellow Yellow Prec HN       Type of Cosmetic Restoration Porcelain Fused to Metal S Crown Full Gold Cinter Tek Press To Metal Pressed Porcelain Lava Procera Inceram Wol-Ceram Feldspathic Veneers Call Me (before proceeding with case) Please evaluate my preps and impressions Return For: Die Trim Evaluation Wax Check biscuit Metal Try-In Finish Margin Design: Porcelain FacialMargin Porcelain Margin 360° Traditional PFM (lingual Metal Band) Show No Metal 360° Metal Margin 360° Mold of Crown Desired: Follow Study Model Match Existing Make Ideal Surface Anatomy: Smooth Mamelon Development Textured Match Existing * Instructions or Comments about the Form Removable: Occlusal Class Smiletype I Vigorous II Soft III Natural     Clasping Akers/Location Tooth# Ring/Location Tooth# I-Bar/Location Tooth# T-Bar/Location Tooth# Modified T-Bar/Location Tooth# Hidden Clasp Tooth#   Rests Mesia/Location Tooth# Distal/Location Tooth# Cingulum/Location Tooth# Channel/Location Tooth# Incisal Rest Tooth#   Major Connector Maxillary Mandibular Horseshoe Palatal Strap A-P Strap Full Coverage Cast Mesh Base Lingual Bar Lingual Apron Kennedy Bar Gate Lock Partial Have you included the following? Impression Bite Opposing Shade Pre-Op Model Photos Model of Temps Anterior Teeth Brand   Mold   Shade  Posterior Teeth Brand   Mold   Shade  Papillameter Reading  mm (InteliDent) Alameter Reading  mm (InteliDent) Stress Breaker Stelligraph De Hinge Lab Select Prosthetics Type Stelligraph Standard Full Denture Immediate Denture Precision Cast Metal partial Flexible Resin Frame Flecible Resin/Metal Frame Stay Plate Custome Tray Bite Rims ProTecTM Permanent Soft Reline Attach Your Document(s) or Photo(s): If you have more than one file, please put them in a zip file.       top

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