RX Form

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Doctor Name
Your Email
Due Date
MM slash DD slash YYYY
Phone
Address
Street Address City State ZIP Code
Patient Name
First Last
Items Included with Case:
- Select All
- Master Impression
- Opposing Impression or Model
- Stick Bite
- Bite Registration
- Impression or model of the Temp
- Photos Emailed
- Facebow Transfer
Teeth to be Restored
Please Select all teeth to be restored:
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
Type of Restoration
Emax Lithium Disilicate #s:
Layered Zirconia #s:
Solid Zirconia #s:
Empress #s:
PFG #s:
Diagnostic Wax-Up
Diagnostic Tooth #s:
Open Bite (in mm):
Vertical Measurement:
Provide Matrix to Fabricate Temps:
Desired Length
Laterals:
Centrals:
Shape
- Follow Temps
- Smile Design Style
Smile Design Style #
Shade of Prepped Tooth
Stump shade teeth #s
Stump shade teeth #s
Shade of Final Restorations
Gingival Shade:
Body Shade:
Incisal Shade:
Occlusal Stain:
Incisal Transluceny
- none
- light
- moderate
- high
Surface Texture
- moderate
- light
- none
Case Info/Instructions
Attach images here (maximum of 5)
Drop files here or

Max. file size: 200 MB, Max. files: 5.
Doctor Digital Signature
By typing your name here you agree that the above is correct.
License #:

Teeth to be Restored