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
__________________________________________________________
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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
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