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843 Quince Orchard Blvd. Ste C&D Gaithersburg MD, 20878 Ph: 240.912.9670 [email protected] www.lintecdental.com Doctor’s Name: Address Phone # Acct # Email Address Paent’s Name: Age Female Male Deliver by 5 p.m. on Review Time: Enclosed with case: Impressions Models Bite Photos Other: Denture Removable Paral Dentures Splints/Nightguards Repair Ivoclar DCL Denture CAD/CAM Denture Immediate Denture Doctor’s Name: Signature License #: Custom Tray Occlusion Rim Wax setup try-in Finish SLA metal frame Valplast Flipper Ultaire AKP Frame try-in Frame w/occlus. Rim Frame w/setup try-in Finish Hard Soſt Hard & Soſt Reline Breaks/Cracks Add Clasp Add Tooth Add Retenon Minor Connector Maxillary Mandibular Clasp Opons Tooth # Rest Areas Tooth # Lab Select Lab Select Lab Select Metal Lab Select Lab Select EstheClasp Thermoflex Removable Addional Notes SHADE

Removable - lintecdental.comRemovable Partial Dentures Splints/Nightguards Repair Ivoclar DCL Denture CAD/CAM Denture Immediate Denture Doctor’s Name: Signature License #: Custom

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Page 1: Removable - lintecdental.comRemovable Partial Dentures Splints/Nightguards Repair Ivoclar DCL Denture CAD/CAM Denture Immediate Denture Doctor’s Name: Signature License #: Custom

843 Quince Orchard Blvd. Ste C&DGaithersburg MD, 20878Ph: [email protected]

Doctor’s Name:AddressPhone # Acct #Email Address

Patient’s Name:Age Female MaleDeliver by 5 p.m. on Review Time:

Enclosed with case:Impressions Models Bite Photos Other:

Denture

Removable Partial Dentures

Splints/Nightguards

Repair

Ivoclar DCL DentureCAD/CAM DentureImmediate Denture

Doctor’s Name: Signature License #:

Custom TrayOcclusion RimWax setup try-inFinish

SLA metal frameValplastFlipperUltaire AKP

Frame try-inFrame w/occlus. RimFrame w/setup try-inFinish

Hard Soft Hard & Soft

Reline Breaks/Cracks

Add Clasp Add Tooth Add Retention

Minor ConnectorMaxillary Mandibular Clasp Options Tooth #

Rest Areas Tooth #

Lab Select Lab Select Lab SelectMetal

Lab Select Lab Select EsthetiClasp Thermoflex

Removable

Additional Notes

SHADE