Crown Tooth #(s) Crown Tooth #(s) Veneer Tooth #(s) Abutment Tooth #(s) IMPLANTS Pontic Tooth #(s)...

Crown Tooth #(s) Crown Tooth #(s) Veneer Tooth #(s) Abutment Tooth #(s) IMPLANTS Pontic Tooth #(s) Inlay/Onlay
Crown Tooth #(s) Crown Tooth #(s) Veneer Tooth #(s) Abutment Tooth #(s) IMPLANTS Pontic Tooth #(s) Inlay/Onlay
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Transcript of Crown Tooth #(s) Crown Tooth #(s) Veneer Tooth #(s) Abutment Tooth #(s) IMPLANTS Pontic Tooth #(s)...

  • Sculpture Plus*

    Gingival

    Middle

    Incisal

    Translucency

    2

    1

    3

    4

    18981 Ventura Blvd. Suite 300 Tarzana, CA 91356 Tel 818-654-7101 Fax 818-758-3559 Toll Free 877-EP4-DDS1 (374-3371) lab@estheticprofessionals.com

    Rx

    Dr. Name AddressPatient Name

    Phone Fax E-mail Date Sent to Laboratory Doctor Due Date

    SHADE & DESIGN Desired Shade: 1 Prep Shade:

    Incisal Translucency 4 : Like Button* Distinct Lobes Ladder #

    Surface texture: Smooth* Anatomical Length of Centrals: mm Laterals: mm Shorter Than Centrals Form (refer to guide #) Occlusal Stain None Light* Medium Heavy

    MATERIAL CHOICE (S) Ceramic

    Conventional (layered) Finess/Empress Stained Layered *

    Zirconium Metal/PFM

    Noble: All Metal

    High Gold* Non-Noble Other Composite

    Premise

    PFM-CROWN/BRIDGE DESIGN Occlusion: Metal Porcelain* Margins: 180 Porcelain 360 Porcelain

    Porcelain Over Metal: Facial* Lingual Metal Collar: Facial Lingual*

    Pontic: Ovate Ridge lap* Relieve Tissue ESTHETIC TREATMENT GOALS

    Change Color Align Teeth

    Close Spaces Close Gingival Embrasures Widen Buccal Corridor Other

    ESSENTIALS TIER PREMIER TIER

    CLASSIC TIER *

    REQUIRED ITEMS CHECKLIST (Anterior Cases)

    Stick bite/Face-bow

    Interocclusal Registration

    Pre-op Models

    Diagnostic Wax-up

    Provisional model + Registration

    Photos: Preparation Provisionals Close-up Full Face

    RESTORATIVE CHOICES Crown Tooth #(s) Veneer Tooth #(s) Abutment Tooth #(s)

    IMPLANTS

    Pontic Tooth #(s) Inlay/Onlay Tooth #(s)

    Other

    Implant Type Implant Size

    Abutment: Custom:Stock Zirconium Cast

    SPECIAL INSTRUCTIONS

    e-max Stained Layered * Stained Layered *

    Doctor’s Signature/ License #:

    PFM Implant Parts: Doctor Will Supply Lab Please Aquire (Write Implant Specs. Above)

    Have Technical Support Call

    City State Zip Age Sex M/ F

    Screw Retained

    CONTACT CHOICES Occlusal Contacts:

    Heavy Medium* Light

    Proximal Contacts: Heavy Medium* Light

    *Used unless otherwise specified

    2 3 1 2 3

    yellow Standard * Budget (Au PT) (Au Pd) (Pb)

    By Signing below, I agree to the terms and conditions listed on the reverse of this document.

    MADE IN THE USA ALL RESTORATIONS

    Diagnostic Wax-up

    Increase Length

    Restoration: Cemented

    (Please select tier)

    Non-Noble

  • By signing this agreement you agree to these terms and conditions of Esthetic Professionals. These terms and conditions may not be modified, or altered without the written and signed approval by an authorized officer of Esthetic Professionals.

    • Past due amounts shall accrue a service fee at the greater of 1.5% per month or the maximum allowed by law, and if applicable a late fee of $25 • If your case is cancelled by you for any reason before shipment, you shall pay all costs incurred in relation to the cancelled order. • You are responsible for any costs of collection, including attorney’s fees and costs associated with them • The payment of the invoice is due in full upon receipt. • Acceptance of a case shall be classified, but not limited to these conditions:

    o 10 days after receipt of case o Installing said case in the patients mouth o Requesting a change to the case, such as but not limited to, shade modification, preparation, or design modification, or modification to the case whatsoever.

    • Rejection/Replacement of case o You must return original case, original impressions, models and restorations to Esthetic Professionals. Esthetic Professionals must have all original materials relating to said case to provide a

    replacement case and allow Esthetic Professionals to asses fault. If you request any modification to original case, not requested in original prescription, additional charges may apply. o If case is determined to be your fault, Esthetic professionals may provide a replacement case within a reasonable amount of time. Your responsibility for all related costs of the replacement product

    and the cost of shipping will be determined by Esthetic Professionals at our discretion. o If case is determined to be Esthetic Professionals fault, you must give Esthetic Professionals the opportunity to provide you with a replacement case within a reasonable amount of time. o If case is determined to be your fault and the fault of Esthetic Professionals, you must give Esthetic professionals the opportunity to provide you with a replacement case. The cost of said case,

    including shipping, shall be shared by you and Esthetic Professionals at the sole discretion of Esthetic Professionals o If modifications to the original case are necessary to satisfy the original order, you must allow Esthetic Professionals the opportunity to modify said case within a reasonable amount of time. o If Esthetic Professionals is not able to remake, or correct defect to case and return the case to you within a reasonable amount of time, your soul remedy is limited to the cost of the product. o We do not warrant the color match of full contour zirconia products to adjacent teeth

    DISCAIMER AND LIMITATION OF LIABILITY. EXCEPT FOR THE TERMS IN THIS AGREEMENT AND EXCEPT AS OTHERWISE PROVIDED FOR IN WRITING BY ESTHETIC PROFESSIONALS WITH RESPECT TO A SPECIFIC PRODUCT BY ESTHETIC PROFESSIONALS, ALL PRODUCTS ARE PROVIDED “AS-IS” AND ESTHETIC PROFESSIONALS MAKES NO OTHER REPRESENTATIONS OR WARRANTIES WITH RESPECT TO THE PRODUCTS. ESTHETIC PROFESSIONALS EXPRESSLY DISCLAIMS ALL WARRANTIES, EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, WARRANTIES OF MERCHANT-ABILITY AND FITNESS FOR A PARTICULAR PURPOSE. NOTWITHSTANDING ANYTHING ELSE IN THIS AGREEMENT, OR OTHERWISE, ESTHETIC PROFESSIONALS SHALL NOT BE LIABLE UNDER ANY CONTRACT, NEGLIGENCE, STRICT LIABLITY OR OTHER LEGAL OR EQUITABLE THEORY FOR (A) ANY AMOUINTS IN EXCESS OF THE ORIGINAL CONTRACT PRICE FOR THE PRODUCT, OR (B) ANY INCIDENTAL, CONSEQUESTIAL OR PUNITIVE DAMAGES, LOST PROFITS, OR ANY LOST REVENUE OR COSTS YOU AND YOUR PATIENTS MAY INCUR IN CONNECTION WITH THE PRODUCT, INCLUDING, WITHOUT LIMITATION, YOUR COSTS OR YOUR PATIENT’S COST IN CONNECTION WITH YOUR SERVICES TO INSTALL, REPAIR OR REPLACE THE PRODUCT.

    You shall indentify, defend and hold Esthetic Professionals and its officers, directors, employees and shareholders harmless from and against any and all claims, liabilities, damages, debts, settlements, costs, attorney’s fees and costs of any kind or nature relating to or arising from your negligence or intentional misconduct.

    Except with respect to injunctive relief, which may be brought in a court of competent jurisdiction, and controversy or claim arising out of or relating to this agreement or the breach shall be settled by binding arbitration. The arbitration shall be held in Tarzana, California, before a single arbitrator having experience with and knowledge of dental technology and the dental business selected in accordance with such rules and regulations unless specifically modified herein. The arbitrators decision shall set forth a reasoned basis in writing for any award or damages or finding of liability including factual findings and legal reasoning upon which the decision is based. The arbitrator shall not have the power to multiply actual damages or award punitive damages or any other damages that are specifically excluded under this agreement, and each party herein irrevocably waves any claim to such damages. The parties shall have all rights or depositions and discovery provided in Section 1283.05 of the California Code of Civil Procedure. This Agreement shall be governed by laws of the United States of America, and in particular, the laws of the State of California, exclusive of its conflicts and principals. The arbitrator shall apply California substantive law and the California Evidence Code to the proceeding. The language of the arbitration shall be English. The arbitrator shall have the power to grant legal and equitable remedies including provisional remedies and award compensatory damages provided by law, but the arbitrator may not order relief in excess of what a court could order. The arbitrator shall not have the power to commit errors of law or legal reasoning or to make findings of fact except upon sufficiency of the evidence any award that contains errors of law may be corrected or vacated as provided by applicable law. The parties covenant and agree that they will participate in the arbitration in good faith and that they will share equally the fees and expenses of the arbitrator. The arbitrator shall asses costs and expenses (including the attorneys’ and experts’ fees and expenses of the prevailing party) against the non-prevailing party to a proceeding. Any party unsuccessfully refusing to comply with an order of the arbitrator shall be enforced in any court of competent jurisdiction. Nothing in this provision shall limit or affect in any way any legal proceedings between the parties to this agreement that has commenced or remains pending to the formation of this agreement.

    If any provision of this agreement is held invalid, unenforceable or void by a court of competent jurisdiction, such circumstances shall not affect the validity of any of the provisions of this Agreement, but this