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Healed Patient in Temporary or Surgical Temporary Form
Healed Patient in Temporary or Surgical Temporary Form
Office Name :
Dr Name :
Ph # :
Email
Patient First Name :
Patient Last Name :
Patient Gender :
Male
Female
Arch being treated :
Maxillary
Mandibular
Both
Gum Tissue Shade :
Light
Medium
Dark
Planned Final Restoration :
Monolithiic Zirconia
Bar / Sleeve
Tooth Shade :
- Select -
A1
A2
A3
A3.5
A4
B1
B2
B3
B4
C1
C2
C3
C4
D1
D2
D3
D4
OM1
OM2
OM3
Files :
- Select -
STL Upper
STL Lower
Bite at correct vertical
Photogrammetry Data
2D Photos (jpeg) (Lip at Rest, High Smile)
3D Extraoral Scan (ply,stl) optional
Notes :
Screw Channel Desired :
- Select -
Let the lab deside
SIN PRH 30
DESS 19.018
Rosen
PowerBall
Vortex
Items to be Returned to Doctor :
- Select -
Prototype for Doctor to Print
Prototype Printed
Screws for case
Due Date
Signature
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