Dentures Department Digital Rx.

Dentures Department Digital Rx.
Dental Office:*
Doctors Name :
Patient full name:*

First NameLast Name
Dental Office address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Due date*

MonthDayYear
Date
Upper / Lower or both*
Shade*
Full Dentures or Partials

Set up for Try In Full DentureSet Up for Try In Partial for Try inAcrylic Partial Straight to finishImmediate Denture straight to finishRemove Remaining TeethFinish Full DentureFinish acrylic partial with wire claspsFinish and Process Acrylic Partial Denture with Flexible clasps or tissue color or Clear
Flexible Partial Dentures

Set up for Flexible partial for Try InFinish and Process Flexible Partial dentureDigital Flexible Partial denture straight to finishNesbit - Unilateral Flexible partialOther
Metal Frame Partial Dentures

Regular Chrome Cobalt Metal Frame with wax rim for bite registrationMetal frame with teeth in wax for try inMetal Frame with Teeth directly to finishAdd Flexible Clasps
Same Day Service

Add Tooth ( Provided )Add Tooth ( Non Provided )Hard Lab RelineSorf Lab RelineRepair crackAdd Wire ClaspAdd Reinforcement Mesh or barWelding Repair
Other Services

3d Print ModelClear ReatinersHard NightguardHawley RetainerAdd Implant AttachmentsCustom TraysHard / Soft NightguardsWax Rims with Base PlatesExxis Partial DenturesOther
Implants

Add Implant Locator housingsAdd Mini Ball Housings with ringsAdd Barr Clips with metal jacketsERA attachments
Drs Note:
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Drs Signature*

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Dr's License Number*
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