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Hard SplintBrux-eze™ SplintRem-e-deze™ SplintGelb SplintComfort H/S™ SplintSports Guard STRAP NO STRAP
Bleaching TrayOther
U L
DENTURE
Occlusion RimCustom TrayOther
U L
PARTIAL
Standard CRCOPremium CRCOwith Occlusion RimAcrylic PartialFlipperSemi PrecisionNew Partial to fit Crown or Bridge
U L
ANTERIOR SET-UPIdeal Characterized Study Model
CHECKLIST
Midline Marked High Lip LineProper Lip Support Emergency (Spare Denture)
Name/Identifier in Appliance
EconomyStandardPremium
U L
Shade
Brand
Mould
ACRYLIC SHADE
Standard EthnicOther MILD MODERATE HEAVY
PARTIAL DESIGN
Lab SelectPalatal StrapHorseshoeDouble Palatal BarLingual BarLingual ApronDouble Bar
U L
Lab Design Complete
MAJOR CONNECTORS
Lab SelectMeshMesh with PostsMetal Pads With PostsOpen Face DummyMetal DummyThermo Flex Dummy
U LSADDLE AREAS
GoldVisiClear™Valplast®
Flexible
U L
TOOTH #
Lab SelectMesial RestDistal RestCingulum RestInverted V RestChannel Rest
U LREST AREAS TOOTH #
Lab SelectSuprabulgeInfrabulge (I-Bar)Flexible Tooth ShadeClear Cosmetic Clasp
U LCLASP OPTIONS TOOTH #
SPLINT
DENTURE & TEETH
Laboratory Procedure Authorization | DR SIGNATURE REQUIREDREMOVABLE PRESCRIPTION FORM
INSTRUCTIONS
R L
UPPER
LOWER
800.259.3717www.dentalservices.net
TEETH
PT NAME
FEMALE MALE
DUE DATE FINISH TRY IN CALL MEENCLOSED WITH CASE: Model BiteArticulator ImpressionsMetal Trays Teeth Photo (Preferred)Shade Tab Other
DR NAME AGEFIRST
LAST
F RR1 01
DR LICENSE #DO YOU NEED? Shipping Boxes
Shipping LabelsFixed Removable
Ortho/SleepStandardImplant
RXS:
TERMS: Net 15th of month. A finance charge of 1½% per month (18% annual) will be added to past due invoices
Cosmetic ValueDR SIGNATURE Local (WHERE AVAILABLE)
For Warranty Information: Please review the DSG Warranty Policy at www.dentalservices.net/dsg-warranty
ADDRESS
PHONESTATECITY ZIP
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