Doctor’s Name ______________________________ Patient _______________ / ________________ Last Name First Name Address/E-mail ______________________________ Phone # (______)______-________ Deliver by 5:00 p.m. on _______________________ See Reverse for Working Times ZIRCONIA Porcelain to Zirconia Fortress Lingual/Occlusal Fortress All-Zirconia* Translucent Opaque IPS e-max Layered Monolithic* IMPLANTS System: _______________________________ Diameter: ______________________________ Parts Sent: _____________________________ CUSTOM ABUTMENT DESIGN MISCELLANEOUS Temporaries/Provisionals Brux Guard Soft/Hard Brux Buard with Guidance Sonamed Playhard Sportsguard Bleaching Tray Surgical Stent Treatment Wax-up Cast Endo Post Laser Weld Soft Tissue Model Gingival Pink Porcelain SHADE ___________________ DENTIN SHADE ____________ Age _________ OCCLUSAL STAIN Send Spectroshade images or pictures to [email protected] PORCELAIN TO METAL Precious Alloy* Non-Precious Alloy FULL-CAST 62% Gold* 50% Gold White Noble WLW Non-Precious DIGITAL FILES ADDITIONAL INSTRUCTIONS DETAIL SHADE, IMPLANT DIAMETER OR CASE INFORMATION __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ PONTIC DESIGN METAL DESIGN PORCELAIN MARGIN PARTIAL Signature _______________________________ License # _______________________________ * Standard unless specified otherwise PLEASE SEND For Lab Use Only ___ Impression(s) ___ Bite ___ Opposing Cast ___ Master Cast ___ Alginate ___ Photos ___ Other _________________________ Date Recv’d ____________ Pan# ______ Retain Pink Copy for Your Records Completed Case* For Dr. to Die Trim Model Work Only (Please Detail Requirements) Metal Try-in Bisque Try-in Wax-up for Review Prefab Abutment Zirconium Titanium Lab’s Discretion Custom Abutment Zirconium Titanium Gold Lab’s Discretion Ideal (Large design may require surgical placement) Blanching OK* (Medium circumference) No Blanching (Smallest circumference) Follow Soft Tissue Contours (Model reflects desired emergence profile) Dark Medium None Light* Spectroshade Digital File Sent File Type _____________________ Facial 360 Under Partial Survey to Receive Shipping Labels Boxes Bio Bags Prescriptions: Impress Removables Surgical Guide M.A.G.O. 10800 Menaul Blvd NE Albuquerque, NM 87112 505-398-9357 impressdentalstudio.com

Albuquerque, NM 87112 505-398-9357 ... - Impress Dental Studio · Treatment Wax-up Cast Endo Post Laser Weld Soft Tissue Model Gingival Pink Porcelain SHADE _ DENTIN SHADE _

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Page 1: Albuquerque, NM 87112 505-398-9357 ... - Impress Dental Studio · Treatment Wax-up Cast Endo Post Laser Weld Soft Tissue Model Gingival Pink Porcelain SHADE _____ DENTIN SHADE _____

Doctor’s Name ______________________________ Patient _______________ / ________________ Last Name First Name

Address/E-mail ______________________________ Phone # (______)______-________

Deliver by 5:00 p.m. on _______________________ See Reverse for Working Times

ZIRCONIA Porcelain to Zirconia Fortress Lingual/Occlusal Fortress All-Zirconia*

Translucent Opaque

IPS e-max Layered Monolithic*

IMPLANTS System: _______________________________ Diameter: ______________________________ Parts Sent: _____________________________

CUSTOM ABUTMENT DESIGN

MISCELLANEOUS Temporaries/Provisionals Brux Guard Soft/Hard Brux Buard with Guidance Sonamed Playhard Sportsguard Bleaching Tray Surgical Stent Treatment Wax-up Cast Endo Post Laser Weld Soft Tissue Model Gingival Pink Porcelain

SHADE ___________________

DENTIN SHADE ____________ Age _________

OCCLUSAL STAIN

Send Spectroshade images or pictures to [email protected] TO METAL

Precious Alloy* Non-Precious Alloy

FULL-CAST 62% Gold* 50% Gold White Noble WLW Non-Precious

DIGITAL FILES

ADDITIONAL INSTRUCTIONS DETAIL SHADE, IMPLANT DIAMETER OR CASE INFORMATION

__________________________________________________________

PONTIC DESIGN

METAL DESIGN

PORCELAIN MARGIN

PARTIAL

Signature _______________________________

License # _______________________________ * Standard unless specified otherwise

PLEASE SEND

For Lab Use Only___ Impression(s) ___ Bite ___ Opposing Cast ___ Master Cast ___ Alginate ___ Photos___ Other _________________________Date Recv’d ____________ Pan# ______

Retain Pink Copy for Your Records

Completed Case* For Dr. to Die Trim Model Work Only

(Please Detail Requirements)

Metal Try-in Bisque Try-in Wax-up for Review

Prefab Abutment Zirconium Titanium Lab’s Discretion

Custom Abutment Zirconium Titanium Gold Lab’s Discretion

Ideal (Large design may require surgical placement) Blanching OK* (Medium circumference) No Blanching (Smallest circumference) Follow Soft Tissue Contours

(Model reflects desired emergence profile)

Dark Medium None Light*

Spectroshade

Digital File Sent

File Type _____________________

Facial 360

Under Partial Survey to Receive

Shipping Labels Boxes Bio Bags

Prescriptions: Impress Removables Surgical Guide M.A.G.O.

10800 Menaul Blvd NE Albuquerque, NM 87112

505-398-9357impressdentalstudio.com

mailto:[email protected]