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165, boul. de la TechnologieGatineau (Québec) J8Z 3G4T : 819.243.5654 / 1.800.207.3895F : 819.243.9498www.milident.com
Boxes
Rx Forms
Pre-printed WayBills
REMOVABLE & IMPLANT PROSTHETICS Rx
MILIDENTLaboratoire dentaire Dental Laboratory
Add _______________________________ Tel ___________________________________
____________________________________________________________________________________
SVP ÉCRIRE EN LETTRES MOULÉES
PLEASE PRINT
SHADE
Dr ________________________________ Pt ___________________________________PLEASE PRINT
SVP ÉCRIRE EN LETTRES MOULÉES
Date ______/______/______J/D M/M A/Y
Signature ________________________________________________________ Licence # _________________________________________________________
DESCRIPTION Rx :
Payable dans les 30 jours suivant la réception de votre état de compte. Payable within 30 days of receiving your statement.
Sex M F
PLEASE SEND
Date required ______/______/______J/D M/M A/Y
Hour _____________
Not booked
Please call me
over closed_____mmover opened____mm
Existing VD_____mmgood
Y
too short_______mmtoo long________mm
Existing CUD____mmgood
X
X______mmY______mm
Papillameter
High lip line______mm
Low lip line______mm
PHOTO COMMUNICATION
Photo included e-mail images to [email protected]
IMPLANT PROSTHETICSImplant supported Overdenture
Reset
CUD / CLD
FinishMetal Reinforcement
Set up
Central dominant Lateral rotation Diastema Irregular lowers
ANTERIOR TEETH ARRANGEMENT
POSTERIOR TEETH Monoplane Semi anatomical Fully anatomical Lingualized
Class I / Class II / Class III
Conventional / Gerber trays
Bite blocks
FrameworkFramework with teeth
Regular AcrilycFlexible Acrilyc
PUD / PLD
Metal with claspMetal with attachmentMetal occlusion
ThermolockHard
SPLINTS
PureflexPankey
Sport guard
JAW RELATION
CUSTOM TRAY
BITE REGISTRATION
TRY-IN
All-on-4Radiographic StentVerification JigMilled barDr. will provide components
Duplicate model(s) Use same mould & teeth arrangement
Anterior Shade_________ Posterior Shade__________ Mould___________
