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RX Lab Slip

Doctor/Practice Name *

Patient Name *

Email Address *

License #

Date

Case Due Date by 5PM

RX Instructions

Finished Shade

Prep Stump Color

Instructions

Restoration Material

Zirconia

Full Contour (monolithic)PFZ (layered)

Lithium Discilicate

Full Contour (monolithic)Layered

Metal

PFM - Non PreciousPFM - Semi-PreciousPFM - NobleGold - 75% Gold AlloyGold - 55% Gold Alloy

Veneers

Lithium Discilicate (layered)Lithium Discilicate (monolithic)Feldspathic

Other

Diagnostic WaxupEsthetic Temps

Implant

Abutment Type

Custom TitaniumCustom ZirconiaStock TitaniumStock Ti-Base

Retention Method

Cement RetainedScrew Retained

Abutment Manufacturer

OEMGeneric

Manufacturer Name

Implant Type

Platform Diameter

Surgical Guide

Radiographic StentImplant StentTooth Born Guide

Removable

Full Denture

Standard analogImmediatePrinted DentureMilled Denture

Nightguard

Comfort (Hard/Soft)Thermo-GuardNightguard

Partial Denture

Standard Cast PartialCast Partial - Frame OnlyFlexible PartialAcrylic Partial

Full Arch

Provisional

PrintedMilled

Final

Zirconia Final ClassicZirconia Final High Esthetic

One Suite Smile

Full Arch Surgical GuideFull Arch Bundle

Other

Smile DesignChair-side ConversionTitanium Bar

Teeth Selection

Based on the image below, please select applicable teeth for this case:

Top Row

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Bottom Row

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Case Photos

Drag and Drop (or) Choose Files

Consent *

Yes, I agree with the Terms and Conditions of Sale

Signature *

Start signing your signature here