crystal labslip hld
TRANSCRIPT
PATIENT NAME
FINISHED
PERMA FINISH
STUDY MODELS 3D IMAGING
TRIM ONLY
MAKE 2 SETS
DUPLICATION FROM DR’S CAST
AGE: D.O.B.
DR. NAME/ OFFICE
LAST NAME
1 2 3 4
5
0
OTHER
6 7 8 9
Years. Months GENDER
FIRST NAME
Perma inked lettering
Typed labeling
Pour impressions twice
M.I.
CASE NUMBER
ADDRESS
CITY STATE ZIP
OFFICE PHONE E-MAIL
CASESRECEIVED
DATERECEIVEDRUSH / SR / HLD OFFICE USE ONLY
DIGITAL BASIC
DIGITAL STANDARD
DIGITAL PLUS
Image only
Image + Trim study model
image + Finished study model
WE NEED:POSTAGEFREE LABELS
SHIPPINGCARTONS
PRESCRIPTIONSHEETS
OTHER
DATE SENT: DUE DATE: RUSH CASEDUE DATE
DISINFECTED BY:(INITIALS)
CRYSTALS T U D Y M O D E L L A B
PERFORMANCE. QUALITY. SERVICE.
14241 Imperial Hwy. Suite A,La Mirada, CA 90638Tel: 562-941-1675Fax: 562-941-4115Email: [email protected]
STL FILE
CAST
IMPRESSION(additional $10.00)
LAB USE ONLYNOTES:
U L B WB
HLD USE ONLY(1 Set )Location #
BIC #
Office NPI #All cases will be processed as regular patient if HLD USE ONLY is not checked