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.Format: (000) 000-0000.
PATIENT NAME
DUE DATE

MonthDayYear
Date
Sex
Age
Facial Type
Teeth Numbers
Type of Restoration
All Ceramic
Temporaries
Metal Ceramic
Full Gold
Tissue Mask
Diagnostic Wax Up
Instructions
Shade
Neck
Cervical
Dentin Gingival
Dentin Mid-Body
Interproximal
Incisal
Incisal Edge
Stump Shade
Facial Margin
Incisal Translucency
Opacity (Value)
Occlusal Stain
Length Desired From Cervical Margin
Centrals (mm)
Laterals (mm)
Canines (mm)
Midline Shift
Right (mm)
Left (mm)
Occlusion Clearance
Frame Design (Please Select From Images Below)
If There is Insufficient Room
Surface Texture
Aoshima P. __ # __
Surface Finish
Aoshima P. __ # __
Gummy Shade Guide
Pontic Design (Please Select From the Options - See Pictures Below)
Pontic Design (mm)
Ridge Relief
Ridge Relief (mm)
Have you Included the Following:
SEND
License #
Do you want us to call you?
DR Signature
Should be Empty:

Length Desired From Cervical Margin