Page 1

Materials:

Shaded area for lab use only.

○ Diagnostic Wax Up

Teeth #s __________________________

Sex: M / F

Items Included with Case:

Shade: Incisal _________________________________________________ Body __________________________________________________ Gingival _______________________________________________ Occlusal Staining: ○None ○Light ○Medium ○Dark

Shade of Preparations:

Stump Shade Teeth # ___________________________ ST _______ Stump Shade Teeth # ___________________________ ST _______ Stump Shade Teeth # ___________________________ ST _______

Length:

Centrals: ______ Laterals: ______ Canines: ______

Shape:

○ Match Photographs ○ Match Provisionals ○ Match Pre-op Model ○ Other: ____________

Incisal Translucency: ○ Minimal (0.5 mm) ○ Moderate (1.0 mm) ○ Maximum (1.5 mm)

○ Master Impression ○ Photos ○ Bite Registration ○ Stick Bite ○ Diagnostic Wax-Up ○ Opposing Impression ○ Pre-operative Models ○ Impression of Provisionals ○ Incisal Matrix ○ CD ○ Memory Card ○ Face bow Transfer Jig

Goal(s) of Final Case: _______________________________________________________ _______________________________________________________ _______________________________________________________ ○ Additional comments on reverse.

Doctor’s Signature

Surface Texture: ○ High ○ Medium ○ Light ○ Smooth

(Qty:____ ) (Qty:____ ) (Qty:____ )

TM

Smile Design

DOCTOR: Patient: Appointment Date: Deliver by 5 P.M. on:

○ All Ceramic Ingot (for lab use only): ________________ ○ Empress Esthetic Teeth #s __________________________ ○ Emax Teeth #s __________________________ ○ Eris Teeth #s __________________________ ○ Lava Teeth #s __________________________ ○ PFM Teeth #s __________________________ ○ Facial Porcelain Butt Margin ○ Simultaneous Facial ○ 360 Porcelain Butt Margin ○ 360 Simultaneous ○ .5mm Lingual Metal Collar ○ .5mm 360 Metal Collar

License #

975 5th Ave NW, Suite 201 Issaquah, WA 98027 tel1: 425.837.1488 tel2: 800.260.0838 fax: 425.427.2483 nwdentalarts.com


Additional Comments:

________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

NW Dental Arts smile design  

Form for providing complete information for dental professionals to complete, to provide NW Dental Arts with all information necessary to pr...

Read more
Read more
Similar to
Popular now
Just for you