Clone of Template

Referring Doctor Name*

Referring Doctor Phone Number*

Format: (000)-000-0000.

Referring Doctor Email*

Name of Dental Practice

License #*

Patient Name*

Patient Phone Number*

Format: (000)-000-0000.

Select Appointment Type Below*

Shade at Lab (SAL)Custom Stain (CS)

Crown is already made but needs color or characterization adjustment (typically darker)
Requires lab modification and staining time
Crown has been loosened or removed prior to appointment. ROE Dental Lab does not remove or decement crowns.
Approximate appointment time: 3 hours

Tooth Numbers*

Has the patient bleached or used whitening strips in the last 2 weeks?*

YesNo

Appointment must be made after bleaching is complete. A two-week wait is required for tooth color to stabilize after bleaching.

Additional Notes