Leixir Dental Laboratory Group
CLIENT PREFERENCES FORM
Name
First Name
Last Name
Doctor License
State
Office Phone
Format: (000) 000-0000.
Doctor Email
example@example.com
Doctor Cell Phone
Format: (000) 000-0000.
Practice Name
Practice Contact Person
Contacts Email
example@example.com
Address
Address
Street Address Line 2
City
State
Zip
Contact Phone
Format: (000) 000-0000.
Primary Method of Communication
Text
Email
Call
Affiliations ex ADA AACD
How did you hear about Leixir
Type of Practice
General Dentistry
Cosmetic
Family Dentistry
Implant
Maxiofacial Surgery
Orthodontics
Periodontics
Prosthodontics
Reconstructive
Restorative
Private Practice
DSO
Reason for Selecting Leixir Dental Group
There are 3 sections below, Fixed, Removable, and Implant Preferences. Please fill in as much info as you can.The more info you provide, the better our work will be for you and less of a chance for a remake.
FIXED PREFERENCES
Preferred Posterior Crown:
Solid Zirconia (or FCZ) (Recommended)
PFZ (Porcelain fused to zirconia)
Lithium Disilicate (EMAX)
CAC (Picasso)
PFM (Porcelain fused to metal)
Nonprecious (silver)
Semi-Precious (silver)
High Noble Yellow Gold
High Noble White Gold
Full Cast Crown
FCC Nonprecious (silver)
FCC Semi-Precious (silver)
FCC High Noble Yellow Gold
FCC High Noble White Gold
Occlusion (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Out of occlusion (default)
Point Occlusion
Way out of occlusion
Interproximal Contacts. (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Normal/ Passive (default)
Broad, Tight contacts
Open
Anatomy (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Match adjacent teeth (default)
Detailed
Minimal
Occlusal Staining
Light (default)
None
Glaze Type (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Low Luster
Medium Luster
High Luster
If Limited Occlusal Clearance
Trim opposing (default)
Trim dye & fabricate reduction coping (voids warranty)
Contact me via cell, text, or email
Tooth Shade Guide Preferred
Vita (default)
Ivoclar
Other
Pontic Design. (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Modified Ridge
No Contact
Full Ridge
Point Contact
Unclear Margins
Call office (default)
Email office with scans (digital)
Return to Doctor (analog)
Make as is (remake fees may apply)
Articulator Type (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Plastic (default)
Panadent
Denar
Kavo
Metal Hinge
Printed
Other
REMOVABLE PREFERENCES Fill out this section if you plan to submit (now or in future) Removable Cases
Digitally Printed Dentures ((CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Standard
Premium
Elite
Do you prefer a post dam on every denture?
Yes
No
Do you want a smile design on very case?
Yes
No
If you would like a smile design, which email should we send this to?
example@example.com
Denture/Partial Base
Acrylic Base (default)
Cast Metal Base
Flex Base
Printed
Other
Occlusal Options
Lingualized Occlusion
Centric Occlusion
MI Occlusion
Denture Teeth
Premium (standard)
Economy
Finishes
100% Muscle Trim
Rugae
Stippling
Smooth
Characterized
Occlusal Guards
Canine Guidance
Flat plane group function
Cast Frame Options
Premium (I.e. Vitallium) - Default
Economy (I.e. Chromium Cobalt)
Preferred Nightguard Type
Hard
Soft
Hard/Soft
Nightguard Finish
Full arch coverage (default)
Anterior coverage
Open anterior
Anterior ramp
IMPLANT PREFERENCESFill out this section if you plan to (now or in future) send us implant cases
Crown Type (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Zirconia (default)
Layered Zirconia
CAC (Picasso)
Lithium Disilicate
PFM
Abutment & Restoration Design (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Custom Milled
Ti Base (Default)
Zirconia
Margin Depth B-F (DEFAULT is 1.5mm) - type your own if you want other than default)
Margin Depth M-D (DEFAULT is .5mm) - type your own if you want other than default
Margin Depth L (DEFAULT Is 0.5mm - type your own if you want other than default)
Place, Restore, or Place and Restore. Who provides parts.
Lab (default)
Doctor
Custom Jig Required (custom abutment only)
Yes
No
Parts Preferences (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Leixir (default)
OEM (Note OEM on RX)
Restoration Design (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Screw-retained (one piece, lab cemented)
Cement (no access hole w. seating jig
Screwmentable (two piece with crown access hole, abutment, seating jig)
Anodized Abutment (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Yes (default)
No
Abutment Margin Depth (TYPE PREFERRED DEFAULT - when you submit a case you can specify different on Rx)
If screw access hole exits facial due to angulation (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Switch to ASC (fees may apply)
Switch to cement
Contact me (text, cell, email)
What ASC Drivers to you use?
Design approval required?
No (default)
Yes
Thank you for filling out this form. By clicking submit below we will e-mail a copy of the completed form to you (doctor e-mail you specified at beginning of this form), and attach it to your Leixir profile so all of our lab technicians can access when you send cases. Thanks for using Leixir Dental Laboratory Group
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