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Clasps
Full Denture
Flexibles
Please send:
Mailing Labels:
Prescriptions Boxes Case Bags
Pre-paid Fed Ex Labels Pre-paid Mail Labels
NDX KELLER160 Larkin Williams Industrial Court
Fenton, MO 63026636-600-4200 • 800-325-3056 NDXKeller.com
DOCTOR:
STREET:
CITY: STATE:
PHONE: FAX:
EMAIL:
ZIP:
PATIENT: (LAST) (FIRST)
AGE:
CROWN & BRIDGEAll-Ceramic
Full Cast Yellow Gold
Porcelain to Metal
IPS e.max®
Empress®
Empress w/ Cutback
Captek™
Non-Precious (White)Noble/Semi-Precious (White)*High Noble (White)
63% 46%* 20%
OcclusionIn Occlusion
Slightly Out of Occlusion*
Out of Occlusion
Shade _____________ or
see shade map
Crown prepped for future partial
PFM Design Chart
Porcelain Butt MarginYes, on tooth # (s) ________
Tooth #’s ______________
Doctor Signature _____________________________________
License No. ___________________________________
Terms are net 10 days from statement date.
DENTURES & PARTIALS
Partial DentureClearFrame™
SoftTite
Metal Frame
All Acrylic
Wire Clasp
Ball Clasp
Clear Clasp
DuraFlex™ *Valplast
Shade: _______________ Mould: _______________
INSTRUCTIONS:
If Alternate Design is Needed, Please Circle
BLingual Collar
Only
CLingual Collar
w/ Narrow Facial
EFull Metal
Lingual
HLingualCollarOnly
JLingual Collar
w/ Narrow Buccal Collar
KLingualCusps Metal
MBuccal Hooded
Porcelain Veneer
Metal Try In Bisque Finish
( )( )
Keller Implant Options
Includes: Titanium Abutment & Choice of Crown.
Znext Layered
Semi-Precious
e.max
Choose ArchUpper
Lower
Try-In*
Complete
Choose Step
Economy
Premium*
Tooth Choice
Pink*
Lt. Ethnic
Dark Ethnic
Choose Acrylic Shade
Send photos to [email protected]
Complete I
Complete II
Default Design is Full Porcelain with No Metal Collars
(Zirconia Substructurew/ Ceramic Overlay)
Implant w/ Abutment Provided by Dr.
Implant w/ Abutment in place
Screw-Retained Crown
Today’s Date: _________________
Return by 5pm on: __________________
MALE FEMALE
Znext Veneered (Zirconia Occlusalw/ Ceramic Facial)
Znext™ Full Contour Zirconia
Znext Anterior Zirconia
Znext Layered
Znext FCZ
Includes: Titanium Abutment & Choice of Crown.
Semi-Precious Enext Lithium Disilicate
Znext FCZSemi-Precious
Znext Anterior
Znext LayeredZnext FCZ Znext Anterior
Znext LayeredZnext FCZ Znext Anterior
Znext Anterior
Upper
Lower
Right Left
not available on Valplast
* Indicates Lab Default
Enext™ Lithium Disilicate
Name in Denture (not available in flexibles)
* Default if not specified.
e.maxEnext Lithium Disilicate
e.maxSemi-Precious Enext Lithium Disilicate
Please include doctor and patient name in email.
** If return date is not specified, will default to regularlab working times. “ASAP” does not qualify as a date.
Implant Prosthetic Guide with an Abutment Placement Guide
