Download - Reliable Dental Laboratory Date · 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

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Page 1: Reliable Dental Laboratory Date · 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

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

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