Dentures Department Digital Rx.
Dental Office:
*
Doctors Name :
Patient full name:
*
First Name
Last Name
Dental Office address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Due date
*
-
Month
-
Day
Year
Date
Upper / Lower or both
*
Please Select
Upper
Lower
Upper and Lower (both)
Shade
*
Full Dentures or Partials
Set up for Try In Full Denture
Set Up for Try In Partial for Try in
Acrylic Partial Straight to finish
Immediate Denture straight to finish
Remove Remaining Teeth
Finish Full Denture
Finish acrylic partial with wire clasps
Finish and Process Acrylic Partial Denture with Flexible clasps or tissue color or Clear
Flexible Partial Dentures
Set up for Flexible partial for Try In
Finish and Process Flexible Partial denture
Digital Flexible Partial denture straight to finish
Nesbit - Unilateral Flexible partial
Other
Metal Frame Partial Dentures
Regular Chrome Cobalt Metal Frame with wax rim for bite registration
Metal frame with teeth in wax for try in
Metal Frame with Teeth directly to finish
Add Flexible Clasps
Same Day Service
Add Tooth ( Provided )
Add Tooth ( Non Provided )
Hard Lab Reline
Sorf Lab Reline
Repair crack
Add Wire Clasp
Add Reinforcement Mesh or bar
Welding Repair
Other Services
3d Print Model
Clear Reatiners
Hard Nightguard
Hawley Retainer
Add Implant Attachments
Custom Trays
Hard / Soft Nightguards
Wax Rims with Base Plates
Exxis Partial Dentures
Other
Implants
Add Implant Locator housings
Add Mini Ball Housings with rings
Add Barr Clips with metal jackets
ERA attachments
Drs Note:
Upload any file from case
Browse Files
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of
Drs Signature
*
Dr's License Number
*
Case Ready for Pick up...
Case Ready for Pick up...
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