R & J Dental Lab Slip

		R & J DentalLab Slip Unit 16B, Kruin Business Center, Tel: +27 12 543 2897 406 Braam Pretorius Rd, Fax: +27 86 599 4011 Magalies Kruin, E-Mail: info@randjdental.co.za Pretoria, 0186

Submission Date*

YearMonthDay
Date
Lab Slip Number*
Expected Return Date*

YearMonthDay
Date
Expected Return Time*
Submitted By
Doctor*
Patient Name*
Patient File No*
Age*
Gender*

MaleFemale
Practice E-mail*
Lab Work

Crown / Bridge / Implant WorkDenturesVacuum Formed PlatesOrthodontic WorkSpecial Dental WorkOther
1) Crown / Bridge / Implant Work
Type

Inlay/OnlayVeneerCrownBridgeImplant Crown - Screw RetainedImplant Crown - CementableImplant Bridge - Screw RetainedImplant Bridge - CementableImplant AbutmentBars And Framework - Screw RetainedBars And Framework - CementableOther
Inlay/Onlay Teeth
eg 21, 22, 36
Veneer Teeth
eg 21, 22, 36
Crown Teeth
eg 21, 22, 36
Crown Post 1
Post Tooth Number
Add another Post

true
Crown Post 2
Post Tooth Number
Bridge 1
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Bridge Post 1
Post Tooth Number
Add another Post

true
Bridge Post 2
Post Tooth Number
Add Another Bridge

true
Bridge 2
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Add Another Bridge

true
Bridge 3
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Add Another Bridge

true
Bridge 4
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Implant Crown - Screw retained Teeth
eg 21, 22, 36
Implant Crown - Cementable Teeth
eg 21, 22, 36
Implant Bridge - Screw Retained
Bridge 1
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Add Another Bridge

true
Bridge 2
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Add Another Bridge

true
Bridge 3
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Add Another Bridge

true
Bridge 4
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Implant Bridge - Cementable
Bridge 1
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Add Another Bridge

true
Bridge 2
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Add Another Bridge

true
Bridge 3
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Add Another Bridge

true
Bridge 4
Unit
eg 4 Unit Bridge
Retainer(s)
eg 21, 24
Pontic(s)
eg 22, 23
Implant Abutment Teeth
eg 21, 22, 36
Framework - Screw Retained Teeth
eg 21, 22, 36
Framework - Cementable Teeth
eg 21, 22, 36
Other Teeth
eg 21, 22, 36
Material
Full Contoured

EmpressE-MaxZirconiaOther
Layered

Empress/ZirconiaE-Max/ZirconiaOther
Add on
Gingiva

true
Color

A1A2A3A4B1B2B3B4C1C2C3C4D1D2D3D4Other
2) Dentures
Type

FullPartialRepairRelineRe-baseOther
Jaw

UpperLowerUpper and Lower
Material

FlexibleAcrylic
Add On

Soft Base
Steps

Special TrayBite RegistrationSpecial Tray and Bite RegistrationTry-inRe-Try 1Re-Try 2Finish
Tooth to be replaced

1112131415161718212223242526272831323334353637384142434445464748
3) Vacuum Formed Plates
Type

Bite PlatesAnti Snoring DeviceOrthodontic RetainerBleaching TrayMouth GuardOther
Bite Plate

SoftHard
Jaw

UpperLower
Color
Orthodontic Retainer

UpperLowerUpper And Lower
Bleaching Tray

UpperLowerUpper And Lower
Mouth Guard Color
4) Orthodontic Work

Orthodontic ApplianceSpace MaintainerSplintOther
Description
Color
Space Maintainer
from
to
eg Teeth 53-55
Splint

UpperLowerUpper and Lower
Special Dental Work

Study ModelsDiagnostic Wax-Up ModelSnap-On-SmileProvisional Restorations
Description
Snap-On-Smile

UpperLowerUpper and Lower
Tooth
To
Color

A1A2A3A4B1B2B3B4C1C2C3C4D1D2D3D4Other
5) Other Work
Special Instructions
Upload a File

Cancelof
Status
Please update status
Current responsible Person
For Lab use only
Model Scan And Casting

YearMonthDay
Design Complete

YearMonthDay
Mill Complete

YearMonthDay
Sinter Complete

YearMonthDay
Finalise

YearMonthDay
Status Date

YearMonthDay
Duration

YearMonthDay
Should be Empty: