Rx
EPIC Laboratory Prescription
Doctor Information
*
First Name
Last Name
Practice
*
Name
City
Office Number
Please enter a valid phone number.
Seat Date
*
-
Month
-
Day
Year
Date
Patient Information
*
First Name
Last Name
Gender
Male
Female
Tooth Number(s)
*
Final Shade
*
Preparation Shade
Are there photos that need to be attached with this case?
*
Yes
No
Was there a digital scan also sent for this case?
*
Yes
No
Choose Restorative Dental Material
Write the tooth number for each material.
Zirconia
Tooth Number(s)
Functional Zirconia (extra strength)
Aesthetic Zirconia (exquisite beauty)
Lithium Disilicate (e.Max)
Tooth Number(s)
IPS e.Max (Press)
ENCORE IPS e.Max (premium $215/unit)
Full Cast Restorations
Tooth Number(s)
Full Cast Noble (yellow colored)
Full Cast High Noble (yellow colored)
Provisional (PMMA)
Tooth Number(s)
PMMA Temporaries
Diagnostic White Wax-Up
Tooth Number(s)
White Wax-Up (includes: Sil-tech matrix, surgical reduction guide)
Night Guard
Upper
Lower
Soft
Hard/Soft
Hard
Design Specifications
Key Details
Desired Length of Upper Centrals
mm
Length of teeth 8, 9
Interproximal Contact Type
Tooth Number(s)
Ideal
Extra Broad
Type of Pontic
Ridge Lap
Modified Ridge Lap
Stein
Sanitary
Ovate
4 Steps for Implants
Please choose one for each of the four steps in restoring implants.
Step 1: Implant Type
Tooth Number(s)
Screw-Retained
Cement-Retained
Step 2: Manufacturer Preference
Tooth Number(s)
Compatible Components
Genuine Manufacturer Components
Step 3: Abutment Selection
Tooth Number(s)
Ti Base (Screw-Retained only)
Custom Titanium
Custom Hybrid (Zirconia)
Prep Stock Abutment
Step 4: Implant Emergence Profile
Tooth Number(s)
Full Anatomical
Tissue Displaced
No Tissue Displacement
Special Instruction
Give further critical information for the case.
Further Instructions
Signature
*
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