Full Arch PMMA Rx
Doctor Name:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email for Copy of Submission:
*
example@example.com
Additional Email for Copy of Submission
example@example.com
Phone:
*
Please enter a valid phone number.
Patient Name:
*
Gender:
Please Select
Male
Female
Delivery by 5pm (12-15 DAYS IN LAB PLUS SHIPPING):
*
-
Month
-
Day
Year
(Please Call for Rush Case)
Select PMMA Prosthesis
Desired Prosthesis
Full Arch Zirconia with Titanium Bar
Full Arch PMMA with Titanium Bar
Full Arch Zirconia (Stain and Glaze)
Full Arch Zirconia (Layered Gingiva / Stain and Glaze Teeth)
Elite Full Arch Zirconia (Layered Gingiva and Teeth)
Full Arch PMMA with Tibases (Pink Composite)
Custom Milled Titanium Bar with Opaque
Pre-Zirconia Setup
Set Teeth back on bar
Process Hybrid
Digital Denture with Pink
Milled PMMA with Layered Pink
Arch Type
Upper
Lower
Both Upper and Lower
Pink Gingiva Preference
*
Regular Pink AnaxDent Composite
Ethnic Pink AnaxDent Composite
Preference Acrylic
USD Acrylic
Naked (No-Pink)
Implant Manufacturer/Connection/Size
Tooth Shade:
The Shades for PMMA and Zirconia are based off Vita Classic/Vita Bleach shade.
Additional Files, Signature and Information
Additional Information:
Call Doctor
No Call Needed
Email ExoViewer (Approval Required)
Provide Angle Correcting Abutments (Extra Charge Applies)
Notes:
Files
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature:
*
License #:
Lab Code
Print
Submit
Should be Empty: