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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