partial denture - dental prosthetic services...partial denture design & estimate only...
TRANSCRIPT
Patient: Age: Youthful Middle-Age Mature Gender: Male Female Shade: Tooth #: Deliver by 5:00pm on:
Doctor : Address: City: State: Zip: Phone: ( ) Special Delivery Instructions:
Partial Denture
Design & Estimate Only Conventional clasping Saddle-Lock (Hidden clasp)
Please indicate your choice of tooth under Full Denture category
Try in Finish case Frame only Frame & bite registration Frame & teeth
Composite/Acrylic Dura-Temp bridge (Stainless steel wings/Composite)
Flipper (Acrylic partial) Softseal gasket partial
Duraflex
I would like a phone call regarding instructions
Doctor Signature
Removable
Full Denture Select Denture Type Value Line Integrity Ultra Line
Other
Ivoclar BlueLine Teeth™
Options for Integrity/Ultra Line Processed base Light cure base
Bite block Pin tracer
Ivoclar Ivostar ™ Teeth
Set up/Try in Finish case
Comments :
Please send my office: Rx (Fixed) Rx (Removable) Rx (Sleep/Ortho) Boxes Mailing Labels
1150 Old Marion Road, NE Cedar Rapids, Iowa 52402
319-393-1990 / 800-332-3341 Fax 319-393-8455
E-Mail [email protected] (Remember to select shade, age, gender, and delivery date)
Dental Prosthetic Services
Flexible Partial
TCS
Valplast