Digital Prescription Form



   Stump Shade:

Implant Abutment

Ceramic                  Custom

Custom w/TI insert     Stock

Emergence Profile: Surgical Placement //  Tissue Displacement //  No Tissue Displacement

Margin Depth: Buccal mm //  Lingual mm //  Mesial mm //  Distal mm

Zirconia / Ceramic Crowns / Provisionals

Bruxzir     Porc. To.                             Temps

       Lava         Porc. To.                             Imp. Temps

                 BioZ         Porc. To.                             Indirect Composite

E-max      Porc. To.                             Veneer

Full-Cast Crowns

Hi Nobel     Semi Precious     Base


A     B     C     D     E

Buccal Margin Design

Supported Margin         Hairline Metal Margin

Porcelain Butt Margin     mm of Margin

Occlusal / Lingual Design

Metal Occlusal Excluding Buccal Cusp     Metal Occlusal Including Buccal Cusp

Maryland Bridge           Metal Lingual Collar           Metal Lingual

PFM Crowns

Hi Nobel     Semi Precious     Base

Dentures / Flexible Partials

Try-in Setup       Process/Finish

Attachment                                                        Gasket

Denture                                                         VDL Band

Duplicate Denture                          Flipper/Acrylic Partial

ThermoFlex Clasp                       TCS Unbreakable Partial

Custom Tray with Holes     TCS Unbreakable/Metal Combo

Custom Tray without Holes                                 Bite Rim

Processed Base                                                  Implant

Name in Appliance:

Set Up: Ideal //  Lingualized //  Characterized

Teeth: Premium //  Standard //  Value


Tissue / Acrylic Shade:

Standard: Light //  Original //  Dark

    Ethnic: Light //  Original //  Dark

Thermoclasp: Clear //  Light Pink //  Shade

TCS Flexible: Clear //  Light Pink //  Std Pink

          Lt/Dark Pink //  Dark Pink

Vitallium 2000 Plus Cast Partials

Frame Try-in     Frame w/Bite Rim

Frame w/Setup       Process/Finish


Rest Areas / Clasp Design

Lab Design     Indicated on Diagram


Splints / Mouthguards / Orthodontics

Sport Guard                Hard Splint

Hard Soft Splint    Hawley Retainer

ESSIX Retainer        Bleaching Tray

Band & Loop                       Nance

Sleep Apnea / Night Guard

SomnoMed MAS                 Silent Nite

Tap III             EMA             Narval

Dual Night Guard    Hard Night Guard


Fracture    Reattach Tooth    Wrought Wire Clasp

Reline                      Weld                      Rebase


Please Send:

RX Pads     Labels     Boxes     Bags


copy the digits from the image into this box