Taking Advanced Dentistry to Exceptional!

PORC. TO ZIRCONIAPARADIGM

DELIVER BY 5PM ON

E.MAX

ALL ZIRCONIA

77% AU - HIGH NOBLE59% AU - HIGH NOBLE50% AU - NOBLE20% AU - NOBLENOBLE WHITENON-PRECIOUS

Rev. 12/26/12

Taking Advanced Dentistry to Exceptional!

Removable

OCCLUSAL RIM

TRIAD BASEPROCESSED BASE (SR-IVOCAP)

SEND US:

RXS AIRBILLSBOXES

PARTIAL DENTURES

ALL ACRYLIC (FLIPPER)

FLEXIBLE

CAST FRAMEWORK

CAST W/TOOTH COLORED CLASP

SHADE ___________

NIGHTGUARDS

UPPER

LOWER

SOFT THEROMOPLASTIC

HARD SR-IVOCAP

FLAT PLANE W/ ANTERIOR GUIDANCE

FLAT PLANE

FULL DENTURES

SET-UP

IDEAL

CHARACTERIZED

FOLLOW WAX RIM

FINISH

SMOOTH

ANATOMICAL

COLOR ____________

IMPLANT BAR (CAD/CAM)

HYBRID

HADER BAR - TISSUE BORNE

DOLDER BAR - IMPLANT BORNE

PRIMARY MILLED

SWISS LOC

LEW PASSIVE

BREDENT VKS

LOCATOR

CEKA

ERA

OTHER _________________________

ENCLOSED WITH CASE

IMPRESSIONS

MODELS

BITES

PHOTOS

SCREWS

ARTICULATOR

FRAMEWORK DESIGN

LAB DESIGN

MAXILLARY TOOTH #

HORSESHOE __________________

CIRCULAR BAR (A-P) __________________

MANDIBULAR

LINGUAL BAR __________________

LINGUAL PLATE __________________

FLEXIBLE __________________

RELINES

HARD (HEAT CURED)

SOFT

REPAIRS

REPAIR

(DESCRIBE IN RX)

Compliant Denture Identi�cation

Patient Accepts (additional $25)

Patient Declines

DELIVER BY 5PM ON

ATTACHMENTS

CLASPING

I-BAR __________________

AKERS __________________

ROACH (T-CLASP) __________________

CLASP TOOTH COLOR __________________

CLASP CLEAR __________________

FLEXIBLE __________________

Rev. 12/26/12

DOCTOR

ADDRESS

CITY STATE ZIP

PHONE

Van Hook Dental Studio now offers and recommends the All-Esthetic Package for your

anterior restorations!

PATIENT NAME AGE MALE/FEMALE

TODAY’S DATE DELIVER BY 5PM ON

DOCTOR SIGNATURE

SHADE

TOOTH #

LICENSE NUMBER

All-Exclusive Implant Solution

Instructions:

Select Abutment and Crown:$499 Titanium Abutment/PFM Crown*

$499 Titanium Abutment/Bruxzir Type Crown*

$499 Titanium Abutment/Zirconia Crown*

*INCLUDES: Lab and Final Screw, Lab Analog, Easy-Place Jig Tissue Model, Shipping and Handling of Parts

**Lab and Final Screw, Lab Analog, Easy-Place Jig, Tissue Model, Shipping and Handling of Parts

INCLUDES

10 DAYSIN LAB

Van HookDENTAL STUDIO

Van Hook Dental Studio, Inc.480.730.5998 | contactus@vhdental.com | vhdental.com

2082 E Southern Ave | Suite 101F | Tempe, AZ 85282

NEW!All-Esthetic Package!**

$599 Zirconia All-Esthetic Package w/Crown**(recommended for anterior)

Terms: Pricing excludes 3% pass-through MDET. Limited to approved platforms. Payments not recieved within 30 days of statement date are subject to a 2% per month service charge. Account balances exceeding60 days will be placed on C.O.D. Prices subject to change without notice. Warranty information available upon request. Rev. 04/13

patient prescription form

Lateral CephalometricFrontal Cephalometric

Digital PhotographyIntraoral & ExtraoralTracing Analysis

Beginning Progress Final

RADIOGRAPHIC STUDIES

3D CONE BEAM CT SCANS

* I hereby assume responsibility for anything that is found within or as a result of the scan. I agree that Van Hook Dental Studio is strictly providing a service to me by providing the scan and therefore is not responsible for anything found in or as a result of said scan.

Patient Name:

DOB: Gender: M / F

Address:

City: State: Zip:

Phone:

PATIENT INFORMATION

REFERRING DOCTOR INFORMATION

Doctor’s Name:

Contact Person:

Address:

City: State: Zip:

O�ce Phone: Fax:

Email:

SCHEDULING INFORMATION

Scan Appointment Date: Scan Time:

Scan Location:

City:

Doctor Signature (Required) Date

State: Zip:

Payment is due when scan services are rendered by major Credit Card or Cash. All appointments will be con�rmed one day prior to scan day.

POST SCANNING SERVICES BY VAN HOOK DENTAL STUDIO (Check all that apply)

Provide DICOM File OnlyProvide DICOM File with I-CAT visionProvide DICOM File and 3D Conversion for Simplant® Planner Pro Provide A Radiology/Pathology Report*

Implant Treatment Planning (Simplant ® Master)Implant Treatment Planning (Nobel Guide/Clinician)

1 2 3 4 5 6 7 832 31 30 29 28 27 26 25

9 10 11 12 13 14 15 1624 23 22 21 20 19 18 17

UR

LR

MAX ANTERIOR

MAND ANTERIOR

UL

LL

Implant ScanVolumetric Airway/Sinus ScanImpaction ScanInfection/Cyst ScanDual Scan ProtocolTMJ Scan Closed Rest Open With Appliance Panoramic Radiograph ScanOthodontic/Craniofacial Scan*

Frontal CephClosed TMJ

Impaction StudyAirway Study

* Orthodontic Scan Includes: Photographs, Panorex, Lateral Cephalometric, Tracings and your choice of two:

MaxillaryMandibular

Master

Certi�ed

Fast TrackSurgiGuide

Master

SimPlant

RSimplantMASTER

Master

Certi�ed

please bring this form on the day of your appointment

Patient Pay Doctor Pay

Van Hook Dental Studio | 2082 East Southern Avenue | Suite 101F | Tempe, AZ 85282 | Phone 480.730.5998 | Fax 480.730.5181 | Toll Free 800.987.4665 | Email contactus@vhdental.com | Web vhdental.com

crystal digital solutionsVAN HOOK DENTAL STUDIO

2082 E. Southern Ave. Suite 101F

Tempe AZ 85282