METAL FREE8510 Crown Crescent Ct Charlotte, NC 28227 704 845 2401 1 800 476 2771 PATIENT’S ID:...
Transcript of METAL FREE8510 Crown Crescent Ct Charlotte, NC 28227 704 845 2401 1 800 476 2771 PATIENT’S ID:...
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By signing above, I acknowledge that this represents the full complete Agreement between parties. This Agreement is subject to the terms /conditions set forth on the reverse side hereof and such terms and conditions are hereby incorporated in their entirety into the agreement.
DR’S SIGNATURE DR’S LICENSE #
d r a k e - Y O U R L A B O R A T O R Y R E S O U R C E PF9/18Made in the U.S.A
PF 9/18
Virginia Use ONLY Instructions GD60-18: ◊ Domestic Lab Approved ◊ Contact Me Before Subcontracting◊ Overseas Lab Approved◊ Either Domestic or Overseas Lab Approved
8510 Crown Crescent CtCharlotte, NC 28227704 845 24011 800 476 2771www.drakelab.com
PATIENT’S ID: AGE: SEX: DUE DATE:
DATE
IMPORTANT INFO FOR THE LAB:
* Default unless otherwise speci�ed
Enclose with case or email them to [email protected] PHOTOS:
FINAL SHADE FOR CROWN / BRIDGE / DENTURE:
STUMPF SHADE FOR FIXED METAL-FREE:
T ISSUE SHADE FOR GINGIVAL:
TOOTH SHADE FOR DURATEK:
Case Disinfected?
IF NO OCCLUSAL CLEARANCE:
Trim OpposingReduction CopingOther___________
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M E TA L F R E E
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Elite Solid ZirconiaValue Solid ZirconiaZ-Sthetic (Ceramic Coverage)Celtra (Press)e.Max (Press)EmpressCeltra (Milled)e.Max (Milled)
Comfort Zone Comfort Zone Plus Hard Acrylic Night GuardSoft Night GuardDream TAP Snore GuardTAP III Snore GuardEMA Snore Guard
G U A R D / S L E E P
DuraTek Solvay Ultaire Valplast Acrylic Cast Metal Unilateral Frame Try-In Bite Rim Wire Clasps Set-Up Process & Finish
PA RT I A L ELITE or VALUE
Traditional Denture Digital Denture Custom Tray Bite Rim Set-Up Process & Finish Reset Reline
D E N T U R E ELITE or VALUE
P F M Tradition High Noble Tradition Noble Value Noble Value Base
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F U L L C A S T Tradition HN Yellow Value Noble Yellow Value Noble White
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