WELCOME
Please fill out the form below to complete your order. Fields marked with a * are required. If you have any questions please call (530) 343-6087. We appreciate your business!
Phone Number:
-
Patient Sex:
Patient Age:
Return Date:
Return Time:
Delivery:
High Noble Yellow Gold
Captek
Noble White Gold
Noble Titanium (white)
Palladium (white)
Base Metal Chrome Cobalt
High Noble Gold Crown (98%)
High Noble Gold Crown (75%)
Noble Metal (50%)
Noble Metal (40%)
Noble Metal (2%)
Titanium (white) - Noble
Palladium (white) - Noble
Chrome Cobalt (white) - Base
Full Crown
Inlay / Onlay
Veneer
e.max Cutback
Full
Bridge
Cutback
Cement on Crown
Two Piece Hybrid (access hole)
One Piece Screw Retained
FDA 510k compliant abutments
Titanium
Zirconia
UCLA
Yellow
White
3/4 Metal Lingual
1/4 Metal Lingual
Full Porcelain Lingual
Metal Hairline
mm on Buccal
Metal Interproximal Margin
Metal Porcelain Junction Margin
Procelain Butt Margin
Coping With Full Porcelain Coverage
Metal Coping With Porcelain Coverage
Metal Occlusal Excluding Buccal Cusp
Metal Occlusal Including Buccal Cusp
Yes
No
Copy Existing Anatomy
Ideal Anatomy
None
Light
Medium
Dark
Metal Occlusion
Reduction Coping
Spot Opposing
Spot Prep
Shade:
Prep / Stump:
Tooth #:
IMP:
Models:
Bite:
Other:
RX Forms
Mailing Labels
UPS Labels
Boxes
Please call me regarding this case
By entering your initials, state, and license number below you are agreeing to digitally sign this prescription form.
License Number:
State:
Initials: