1. No category

• STANDARD RX •
Doctor:________________________________________________________________ Patient Name:_________________________________________________________________ Age:____________
Contact No:___________________________________________________________ Email / Whatsapp No:_________________________________________________________________________
Head Office - Mumbai: 402, Akruti Arcade J. P. Road,
Opp. A. H. Wadia School, Near Andheri Sport Complex, Andheri (W),
Mumbai- 400053. Tel: 022-61437900
Head Office For Rest Of India: 106, Shreyas Industrial Estate,
Behind Monginis Factory, Opposite City Mall,
Off New Link Road, Andheri [West], Mumbai - 400053 India.
Tel: 022-61438500
Date:________________________________________ Delivery Date:_____________________________________________
Enclosed With: ? Imp Upper
Restoration Type: ? Joint Crowns
? Imp Lower
? Bite
? Separate Crown
? Model Upper
? Model Lower
? Other_____________
? Bridge
RESTORATION ON TOOTH
SHADE
MARGIN
OCCLUSAL STAINING
? Shoulder Margin
8 7 6 5 4 3 2 1
? None
? Medium
? Gingival Margin
1 2 3 4 5 6 7 8
? Light*
? Dark
IF NO OCCLUSAL CLEARANCE
8 7 6 5 4 3 2 1
NON-PRECIOUS
? Call Doctor
? Mark Opposing
1 2 3 4 5 6 7 8
Bruxzir CAD/CAM
LAVA
? PFM
? Bruxzir Crown
? Lava Premium
? PFM Facing
? Bruxzir Bridge
? Lava Classic
? Full Metal
? Bruxzir Inlay / Onlay
? 3M Essential
Tilite CAD/CAM
? 5YW Ultra-T Crown
? Tilite Facing
? 5YW Ultra-T Bridge
? Tilite Full Metal
? Tilite Inlay / Onlay
5YW PFM CAD/CAM
? 5YWTM PFM
? Laminate
Modified Ridge
? Bisque try-in
? Finish
Full Ridge
Hygienic
Ovate
? Inlay / Onlay
? 5YW Zircon Crown
COLLAR AND METAL DESIGN
? 5YW Zircon Bridge
IPS EMPRESS
MISCELLANEOUS
? Single Crown
? 5YW Facing
? Mockup
? Laminate
? 5YWTM Full Metal
? Provisional
? Inlay / Onlay
TM
? Metal try-in
? Coping try-in
IPS EMAX
? Single Crown
5YW ZIRCON CAD/CAM
STAGE
PONTIC DESIGN
5YW ULTRA - T CAD/CAM
? Tilite
? Metal Island
Specifications
No Collar
Lingual Collar
Request: For implant restorations please fill in the implant Rx
For Lab Use
Case No:
In time:
? 2nd Rx
Note: Please send a bite registration along with the upper & lower rubber base impression.
An Rx with complete information will be highly acknowledged for the lab to work swiftly.
3600 Collar