Hopetown Dental Lab
705 W. Bailey Boswell, Suite 300
Saginaw, TX 76179
682.554.0228
Hopetown
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Hopetown Dental Lab
705 W. Bailey Boswell, Suite 300
Saginaw, TX 76179
682.554.0228
Hopetown
D
E
N
T
A
L
L
A
B
Doctor’s Name
Patient’s Name
Doctor’s Name
Patient’s Name
Today’s Date:
Seat Date:
Today’s Date:
Seat Date:
TURNAROUND TIME: (Contact Lab for all cases faster than standard turnaround)
q Standard 5 Days In House q 2 Days In House q Next Day q Same Day
TURNAROUND TIME: (Contact Lab for all cases faster than standard turnaround)
q Standard 5 Days In House q 2 Days In House q Next Day q Same Day
CROWN: (Please Check One)
CROWN: (Please Check One)
q Full Contour Zirconia
q Porcelain Fused to Zirconia
q IPS e.max
q Porcelain Fused to Metal
q Empress
q Lava Ultimate
q VITA
TOOTH
SHADE
q Non-Precious
q Semi-Precious
q Noble
q Porcelain Fused to Zirconia
q IPS e.max
q Porcelain Fused to Metal
q Empress
q Full Contour Gold
q Non-Precious
q Semi-Precious
q Noble
q Full Contour Zirconia
q Lava Ultimate
CROWN
NUMBER(S)
ABUTMENT:
q VITA
q Non-Precious
q Semi-Precious
q Noble
q Full Contour Gold
q Non-Precious
q Semi-Precious
q Noble
CROWN
NUMBER(S)
ABUTMENT:
q Zirconia Abutment with Titanium base
q Zirconia Abutment with Titanium base
q Titanium Abutment
OCCLUSAL
CONTACT
q Other
q In Occlusion
SPECIFIC INSTRUCTIONS:
q Light Occlusion
q Titanium Abutment
OCCLUSAL
CONTACT
q Other
q In Occlusion
SPECIFIC INSTRUCTIONS:
q Light Occlusion
q Out of Occlusion
Signature
TOOTH
SHADE
License#
By signing this prescription, I acknowledge all above information is accurate. I also agree to pay Hopetown Dental Lab for all products and services by the 30th of the following month.
q Out of Occlusion
Signature
License#
By signing this prescription, I acknowledge all above information is accurate. I also agree to pay Hopetown Dental Lab for all products and services by the 30th of the following month.