Name: 

DDS: 

yes no

DMD: 

yes no

Practice Name: 

Street Address: 

City: 

State: 

   Zip Code: 

Phone: 

Email: 

CROWN AND BRIDGE

Metal Collars:

Anteriors:

yes no

Posteriors:

yes no

Metal Occlusals:

yes no when needed

May we relieve the opposing tooth?

yes no

If model looks distorted, may we call you?

yes no

Contacts:

yes no point normal broad oval heavy indicated on prescription

Preferred Alloy: 

predominantly base noble high noble

Staining: 

none natural heavy characterization indicated on prescription

Occlusal Clearance: 

in occlusion out of occlusion foil relief

DENTURES

Trays: 

solid perforated

Bite Blocks: 

stabilized base wax base

Tooth Selection: 

hardened acrylic composite resin reinforced

Occlusals on Posterior Teeth: 

zero degrees twenty degrees thirty degrees lingualized functional indicated on prescription

Set-up: 

ideal aesthetic

Palatal Relief: 

yes no

Palate: 

smooth anatomical

Carved Labial Buccal: 

yes no

Stippled: 

yes no

Polish Peripherals: 

yes no

Full Roll: 

yes no

Finish Base Material: 

lucitone 199 indicated on prescription

CAST PARTIALS

Preferred Clasp Design: 

1. 
2. 
3. 

Can We Change Design If Necessary? 

yes no

Should We Call You About Any Design Changes That Would Improve Aesthetics or Retention?  

yes no

Type of Major Connector: 

Upper   

Lower  

Framework Try-in: 

yes no

Framework with Set-up Try-in: 

yes no indicated on prescription

Type of Teeth on Framework: 

plastic porcelain (when possible)

Finish Base Material: 

lucitone 199 characterized lucitone plain lucitone indicated on prescription

Other Comments or Instructions:

Would you like a copy of this
information e-mailed to you? 

yes no