Patient's Name:
Age
Shade
Doctor's Name:
Date To Be Returned:
 
Bridge Crown PFM (porc. fused to metal)
Zirconia FCC (full cast crown or inlay/onlay)
Separate Post Composite Crown/Inlay/Onlay
Telescopic Coping Diagnostic Wax Up
 
Pressed Ceramic  
Crown Veneer Inlay/Onlay
 
Temporary  
Short Term Reinforced
 
Metal Design  
Lingual Metal Band Facial Metal Band
No Facial Metal No Collar 360
Porcelain Shoulder Crown/Fit Partial
Metal Occlusal/Lingual
Rest Lingual
Mesial Distal
 
Alloy  
High Noble Yellow
Noble White
 
Occlusal Anatomy
Worn Light Copy Existing
 
Pontic Design  
Ridge Lap Partial Ridge Lap Point Contact
 ridgelap  partialridgelap pointcontact
No Ridge Lap No Contact
 noridgelap  nocontact
 
Articulator    
Denar Hanau KAVO
 SAM Panadent Stratos
Metal Hinge Plastic  
Facebow Enclosed Enclosed, Serial #
 
Return For    
Die Trim Check Bisque Bake Metal Try-In
Insertion Mounting
 
Full Denture  
Mold
 
Resin Teeth    
Vitapan IPN Ivoclar
Denture/Partial
Reline Rebase Soft Liner
Repair Attachment Type
  
Acrylic    
Standard Acrylic Gingival Toning Ethnic
 
Surgical Stent Custom Tray Bite Rim
Process and Finish Set Up Try In Night Guard
Sports Guard    
 
Partial Dentures  
Cast Frame All Acrylic Partial
Flexible Partial Horseshoe
 
Upper Palatial Strap  
Anterior Posterior
Open Palate Other
 
Lower    
Lingual Bar Lingual Plate Finish
Frame Only Kennedy Bar Other
Frame Try-In w/Setup Frame Try-In Bite Blocks
 
Patient's Dexterity
 
 
Implant Prosthetics
Brand Size
Ceramics/C&B Cement Retained
Custom Abutment CAD Milled Abutment
Screw Retained Fixed/Detachable
Overdenture w/Cast Bar Overdenture w/Attachment
 
     
8
7
6
5
4
3
2
1
32
31
30
29
28
27
26
25
teethnumbered
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Patient Desires
Natural Characterized Shade
Copy Natural Alignment
Strait Alignment
Overlapped
 
 

Add comment


English (United Kingdom)
feed-image
Delicious