2065 W Woodland • Springfield, MO • 65807• 800.462.3569 •

65 W Woodland • Spr800 462

Impression

Facebow

Attachment

Articulator

Special Instructions:Please call Please Text: #

Papillameter:

Alma Gauge:

Has this case been disinfected?

Occlusal Scheme:

Master Model

Implant Components

Opposing Model

Framework

Dr.

Address:

City:

Phone:

Patient:

Male Female

Return Request Date: Time:

Date:

State:

Zip:

Age:

Old Crown

Photos

Bite Relation

Payment is due upon receipt of statement. Payment not received by the end

of the following month is subject to a 1.5% per month service charge on the

unpaid balance plus all collection costs if incurred.

Your signature is acceptance of these terms.

Each prescription must be completed and signed.

X

Doctor Signature License Number

ENCLOSED WITH CASE

Upper

Lower

Immediate

Essential

Artisan

Anterior:

Posterior:

Tooth #:

Tooth #:

Tooth #:

Shade:

Upgrade to:

Replacing

Clasping

Tooth #:

Tooth #:

Shade:

Replacing

Clasping

DENTURE

Shade:

Premium

Standard Med. Ethnic

Miscellaneous: Bleaching Trays

Light Ethnic Dark EthnicCast Wire Clear Pink Tooth Color

Cast Wire Clear Pink Tooth Color

Rebase

Repair:Reline:Add Clasp:

Base

Hard

Cast

Tooth

Soft

Wire

Nesbit Unilateral

Frame Design Only

Frame Try-In

Wiro-Flex (Nylon/Chrome Hybrid)

Frame / Wax Rim

Frame / Teeth

Frame / Teeth Processed

Flexible Partial

Soft-Grip Partial

Processed Acrylic

Flipper (Self-Cure)

Unilateral

Try-In

Set-up

Process

Bite Rim

Digital Scan:Date Sent:

System:

Time Sent:

High:

Vert:

Low:

Horiz:

NoYes

UPPER LOWER

Are you a Signature Account?

Yes No

Reset

Custom Trays

Intraoral Tracer

FULL DENTURE

DENTURE / PARTIAL SUPPORT SERVICES

ALL RX FORMS

PARTIAL DENTURE

METAL - FREE

CAST METAL

DENTURE BASE SHADE

Follow the QR Code to print more Rx forms

www.EdmondsDentalProsthetics.com/resources

Print 2 copies of completed script, keep one for your records and send the other one with the case. 10/21