Integrity Dental Services Implant Rx
Doctor Name:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name (If Different from Doctor Name):
Best Contact Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best Contact Method
Phone Call
Email
Text
Delivery by 5pm: (12 IN LAB DAYS PLUS SHIPPING)
*
 -
Month
 -
Day
Year
(Please Call for Rush Case 470-222-2902)
Patient Name:
*
Gender:
*
Please Select
Male
Female
Email for Confirmation Receipt:
*
example@example.com
Additional Email for Copy of Confirmation
example@example.com
Tissue Compression Preference
Please Select
Highwater
Light
Standard
Tight
Occlusion:
*
Copy the occlusion exactly as is
Adjust the occlusion on articulator
If adjusted, cantilever contact?
Please Select
Yes
No
If yes, in CR and/or in Excursive?
Please Select
CR
Excursive
CR and Excursive
Design:
Facial screw tissue: If the screw is coming out facially, do you want us to use ASC? (Angled Screw Channel)
Facial embrasure definition: Do you want us to define them more?
Cantilever Reinforcement - Adjust prosthetic to a minimum of 3mm thickness around caps and access holes
Cantilever Reinforcement - Bulking up posterior papillaes (mesial and distal to the most posterior cylinder)
Redefine anatomy of occlusal surface?
Ideal
As-is
Other
Occlusal Guards:
Hard-Soft Vaccu Formed
Hard Night Guard - Contact with anterior ramp
Hard Night Guard - Contact without anterior ramp
Hard Soft Night Guard
Select Implant Prosthesis
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 (Naked)
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
(Digital) Milled PMMA Naked
(Digital) Milled PMMA with Layered Pink
Tooth Shades:
The Shades for PMMA and Zirconia are based off Vita Classic/Vita Bleach shades
Additional Information
Call Doctor
No Call Needed
Provide Angle Correcting Abutments (Extra Charge Applies)
Upper
Full Arch
Lower
Partial Arch
Notes:
Files
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Will this case include physical models sent to Integrity Dental Services?
Yes
No
Please Provide Tracking Number
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Implant System:
Gingiva Shade:
Signature:
*
License #:
Lab Code
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