Reliable Dental Laboratory Date · Same Day Reline / Repair must be scheduled in advance, and will...
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Reliable Dental Laboratory 10610 Metric Dr. #191, Dallas Texas 75243 (972) 272-5511 Fax : (214) 503-8686 . Texas Reg #2827 Removable & Hybrid RX Email: Dr. / Office. Patient: Date Requested: Date: Enclosed with case: Impressions Models Bite Photos Study Model Dark Medium Dark Light Shade Original TISSUE Shade TOOTH Shade: TOOTH Setup: Ideal Characterized Please Check Male Copy Existing Denture Copy Study Model Female Age Implant System Implant Diameter mm Teeth to be extracted from model now Teeth removed from model at final processing ( A-P Spread is 1.5 X A.P ) First molar occlusion Standard Process & Finish Premium Teeth in Wax Try-In Implant Verification Jig Reset Immediate DENTURES Upper Lower Final Prosthesis Flipper ( 1-3 Teeth ) Upper Lower Acrylic Partial ( 4 teeth or more ) Unilateral Teeth in Wax Try - In Process & Finish CLASP OPTIONS Wrought Wire Ball Clasp T Clasp Additional Instructions: ( Please Print legibly) Dentist’s Signature Same Day Reline / Repair must be scheduled in advance, and will be subject to a RUSH Fee LICENSE NO: Locator Bar Overdenture Solid Zirconia Hybrid Denture Upper Lower Duplicate Denture Custom Tray Biteblocks Lower Hard Reline Soft Reline Bleaching Tray Rebase Repair Surgical Guide Patient ID Screw-Retained Hybrid Denture Locator Overdenture Lab Select Horseshoe Lingual Plate CLASP DESIGN MAJOR CONNECTOR Lingual Bar Palatal Bar Full Palate Lab Select Clasp Akers Clasp Ball Clasp Clear Flexible Clasp Wrought - Wire Clasp Other Upper Lower Frame W / Biteblocks Frame Try - in Only Frame W / Teeth In Wax Premium Teeth Extra Process & Finish Upper Lower Hard (Clear Acrylic ) Soft NTI Sports Guard Thermoguard NIGHTGUARDS SPLINTS Band and Loop Hawley Retainer Essix Retainer Other ORTHO APPLIANCES Upper Lower Teeth in Wax Try - in One Stage Complete FLEXIBLE PARTIALS Upper & Lower Models with Protrusive bite required SNORING / SLEEP APNEA APPLIANCES: Process & Finish Premium Teeth Extra TAP III Silent Night Upper CAST PARTIALS ACRYLIC PARTIALS REMOVABLE EXTRAS IMPLANT DENTURE APPLIANCE 1 32 31 26 13 12 15 9 14 27 11 6 16 8 10 7 5 4 3 2 17 29 25 30 22 24 28 23 21 20 19 18 UPPER LOWER The Statement Blanace is due and payable by 30 of the month following purchase. Accounts with outstanding balances over 30 days will be subject to COD status. if you have any questions please contact [email protected] Rev 4/4/2019 th th
Transcript of Reliable Dental Laboratory Date · Same Day Reline / Repair must be scheduled in advance, and will...
Reliable Dental Laboratory10610 Metric Dr. #191, Dallas Texas 75243
(972) 272-5511 Fax : (214) 503-8686.Texas Reg #2827
Removable & Hybrid RX
Email:
Dr. / Office.
Patient:
Date Requested:
Date:
Enclosed with case: Impressions Models Bite Photos Study Model
Dark
Medium Dark
Light Shade
Original
TISSUE ShadeTOOTH Shade:
TOOTH Setup:
Ideal Characterized
Please Check
Male
Copy Existing Denture
Copy Study Model
Female
AgeImplant System
Implant Diameter mm
Teeth to be extracted from model now
Teeth removed from model at final processing
( A-P Spread is 1.5 X A.P ) First molar occlusion
Standard
Process & Finish
Premium
Teeth in Wax Try-In
Implant Verification JigReset
Immediate
DENTURES
Upper Lower
Final Prosthesis
Flipper ( 1-3 Teeth )
Upper Lower
Acrylic Partial ( 4 teeth or more )
Unilateral
Teeth in Wax Try - In
Process & Finish
CLASP OPTIONSWrought Wire
Ball Clasp
T Clasp
Additional Instructions: ( Please Print legibly)
Dentist’s Signature
Same Day Reline / Repair must be scheduled in advance, and will be subject to a RUSH Fee
LICENSE NO:
Locator Bar Overdenture
Solid Zirconia Hybrid Denture
Upper Lower
Duplicate Denture
Custom Tray
Biteblocks Lower
Hard Reline
Soft Reline
Bleaching Tray
Rebase
Repair
Surgical Guide
Patient ID
Screw-Retained Hybrid Denture
Locator Overdenture
Lab Select Horseshoe
Lingual Plate
CLASP DESIGN
MAJOR CONNECTOR
Lingual Bar Palatal Bar
Full Palate
Lab Select Clasp
Akers Clasp
Ball Clasp
Clear Flexible Clasp
Wrought - Wire Clasp
Other
Upper Lower
Frame W / Biteblocks
Frame Try - in Only
Frame W / Teeth In Wax
Premium Teeth Extra
Process & Finish
Upper Lower
Hard (Clear Acrylic )Soft
NTI
Sports GuardThermoguard
NIGHTGUARDS SPLINTS
Band and Loop
Hawley RetainerEssix Retainer
Other
ORTHO APPLIANCES
Upper Lower
Teeth in Wax Try - in
One Stage Complete
FLEXIBLE PARTIALS
Upper & Lower Modelswith Protrusive bite required
SNORING / SLEEP APNEA APPLIANCES:
Process & Finish
Premium Teeth Extra
TAP III Silent Night
Upper
CAST PARTIALS
ACRYLIC PARTIALS REMOVABLE EXTRAS
IMPLANT DENTURE APPLIANCE
1 32
31
26
13
12
15
9
14
27116
16
8 107
5
43
217
29
25
30
2224
28
23
21
20
19
18
UPPER LOWER
The Statement Blanace is due and payable by 30 of the month following purchase. Accounts with outstanding balances over 30 days will be subject to COD status. if you have any questions please contact [email protected] Rev 4/4/2019
th th
