MILLENNIUM DENTAL LABORATORY RX FORM

MILLENNIUM DENTAL LABORATORY RX FORM
98 Cuttermill Road Great Neck, NY 11021 Tel: (516) 504-0088 Fax: (516) 504-8811 Email: rmaiberg@aol.com
DR
RX Date

MonthDayYear
Date
ADDRESS
CITY
STATE
ZIP
Phone Number
Please enter a valid phone number.
PATIENT NAME
DUE DATE

MonthDayYear
Date
Sex

MaleFemale
Age
Facial Type

SquareOvoidSquare TaperingSquare Ovoid
Teeth Numbers

1234567891011121314151617181920212223242526272829303132EvaluationDie TrimWax-upTry-inBisqueFinish
Type of Restoration

VeneerCrownBridgeInlay/OnlayImplantMaryland Bridge
All Ceramic

IPS e-maxZirconiaFeldspathic Veneer
Temporaries

TEMPS
Metal Ceramic

Yellow Prec. HNWhite Prec. HNSemi Prec. N
Full Gold

Type option 1
Tissue Mask

YesNo
Diagnostic Wax Up

Tooth Wax UpTissue Wax UpDiagnostic StentPrep Guide
Instructions
Shade
Neck
Cervical
Dentin Gingival
Dentin Mid-Body
Interproximal
Incisal
Incisal Edge
Stump Shade
Facial Margin

Porcelain Butt MarginShow No MetalMetal Margin 360Show No Metal 360
Incisal Translucency

0.5 mm1.0 mm1.5 mm
Opacity (Value)

HighMediumLow
Occlusal Stain

NoneLightMediumDarkINC. HALO
Length Desired From Cervical Margin
Centrals (mm)
Laterals (mm)
Canines (mm)
Midline Shift
Right (mm)
Left (mm)
Occlusion Clearance

In OcclusionFoil ReliefOut of Occlusion
Frame Design (Please Select From Images Below)

ABCDEFG
If There is Insufficient Room

Reduce and MarkPlease CallReduce Coping
Surface Texture

HighMediumLightSmooth (no texture)Aoshima P.
Aoshima P. __ # __
Surface Finish

High GlazeMedium GlazeSatin FinishLow GlossAoshima P.
Aoshima P. __ # __
Gummy Shade Guide

LightMediumDark
Pontic Design (Please Select From the Options - See Pictures Below)

SanitaryFull RidgeModifiedBuffetOvate
Pontic Design (mm)
Ridge Relief

YesNo
Ridge Relief (mm)
Have you Included the Following:

Impression/MasterBiteOpposing ModelBite StickStudy ModelTemps ModelShade TabPhotos/SlidesFace BowArticulator
SEND

RX’sBoxesAirbills
License #
Do you want us to call you?
DR Signature

Clear
Should be Empty:

MILLENNIUM DENTAL LABORATORY RX FORM

Length Desired From Cervical Margin

Midline Shift