Age:Patient:

Address:

Case Due Date:

Airbills

Mailing Labels

Boxes

Smile Design Rx

RX-Prescriptions

Please Send

Please Call the Dentist

Brux Crown:

Lava: 1 to 6 units anywhere in the mouth

All-Ceramic Restorations (Please indicate stump shade)

Captek 24k gold

Cerec: Digital Impression, e.Max, Empress, Zirconia, Brux Crown (CAD/CAM)

Procera: Crowns anywhere in the mouth

Chromatech: Feldspathic veneers.

Porcelain to Metal

Base Alloy

White Noble

White High Noble

Yellow High Noble

Full Cast Crowns

Base Alloy White

Base Alloy Yellow

White Noble

Fixed

Gold High Noble

VALPLAST

ULTRAflex

CLEARsplint Niteguard

Ortho Appliance

Frame Try-in

Setup Try-in

Fully Fabricate

Process / Finish

Temporary

Patient Information:

Margins

Porcelain Shoulder

MetalPorcelain to Metal

With Lingual Band

Occlusion

Metal Occlusion

IN Occlusion

OUT of Occlusion

Surface Texture

Smooth

Moderate

Heavy

Doctor's Technical Preference

Porcelain Occl.

Implants

Contacts

Metal Preferences

High Yellow Noble

High White Noble

White Noble

Base Alloy

Heavy

Medium

Light

Custom Abutment

Gold Noble

Removable Surgical Guide

Scan Guide

Other Temporaries

Other

Reduce Opposing

Cutting Coping

Terms: Accounts are due and payable upon receipt. A 2.5% monthly service charge will be added to all account balances after the 20th of each month. Balances that become 60 days past due will go on an automatic COD basis collecting the total balance due. Delinquent accounts will also be responsible for any/all legal costs and collection charges. Your signature indicates personal guarantee of these terms. All fees are due and payable in Bexar County, San Antonio, Texas

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Doctor's Instructions for Case:

Excellent Fair PoorPatient:

Shade:

Stump Shade:

Quality Control on Previous Case

Removable Appliances

Signature

Lava Cerec Hybrid

Empress: Crowns, veneers or inlays.

e.Max: Crowns anywhere in the mouth.

W/o Lingual Band

Male

Female

After hours number

Todays Date:

Doctor:

Address:

City: ST: Zip Code:

Phone #

1950 Bandera Road San Antonio, TX 78228

1.800.683.1025 Local #: 210.735.1433 FAX #: 210.735.2127

www.authenticlab.com Texas Reg# 01470

Dr. Lic#

email:

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Copyright PACT Consulting, LLC

(CAD/CAM) Cement or bond

(CAD/CAM) Cement or bond

Indicate layered or stained. Must be bonded

Must be bonded

3-unit anterior bridges Cement or bond

DESIGN UPPER

DESIGN LOWER