Doctor Information
Dr.
Address
City:
Phone: (
)
Alternate Phone: (
E-mail Address:
Website:
Date:
State
Fax: (
)
Zip
)
-
/
-
/
Practice Name:
Office contacts for:
Billing:
Office Hours:
M
T
W
Doctor’s Birthday:
Dental School:
Scheduling:
TH
F
S
Terms
Full payment is due upon receipt of statement. There will be a 2% month service charged for any payment or portion
thereof not received with the said 30 days until payment is received in full.
Payment Preference
Pay my bill by check each month for the current monthly balance
Pay by Credit Card (process automatically)
Call me
I will call
COD
License #________________________________
Tech/Rep _______________________________
Signature________________________________
Point
Occlusal:
Light Normal
Foiled
Out of Occlusion
Notes: ................................................................................................................................
Occlusal
Staining
Inter Proximal:
Normal Broad
Light Heavy
Ceramic:
C&B:
Noble/Semi Precious Non Precious
Noble High Noble Yellow
High Noble Yellow High Noble White
Non Precious High Noble White
Feather Edge
Shoulder
Beveled Shoulder
No Collar/ Full Porcelain Coverage
Small Lingual Collar
Small Lingual & Buccal Collar,
Metal Lingual/Occlusal
Other
Pontic Design
Chamfer
Metal Design
Type of Margins
Notes: ............................................................................................................................................................................
Porcelain Finish
Surface Texture
Alloys
Contact
Fixed Preferences
Smooth
Moderate
Other
Ovate
Bullet
Full
Ridge Lap
Modified
Ridge Lap
Sanitary
If occlusal clearance is a problem, what would your preferred method of correction?
Call Doctor
Reduce
Prep
Send Reduction Coping
Relieve Opposing
Metal Occlusal
Additional Instructions/Comments:
Tech/Rep _______________________________
Signature________________________________
Normal
Bead
Heavy
Other ...........................................
Horseshoe
Kennedy Bar
Palatal Strap
Double Bar
(Anterior/Posterior)
Lingual Bar
Degree of Cusp
Type of Teeth
Yamahachi
Ivoclar
Dentsply
Other ..................................................
Rugae
Characterized/Gingival Anatomy
Stipple
Other ..............................................................
Cast Partial
Frameworks
Butterfly
Light Cured
Finish
Non Perforated
Vacuum Formed
Clasp
Connector
Post Dam
Tray
Perforated
Base Plates
Removable Preferences
Clasp as survey indicates
RPI
Circumferential
E-Type CLasp
T-Roach Clasp
Akers
0°
10°
20°
33°
Modify
Design as
Needed
Follow
Design
Additional comments or instructions:
Tech/Rep _______________________________
Signature________________________________