Hard SplintBrux-eze™ SplintRem-e-deze™ SplintGelb SplintComfort H/S™ SplintSports Guard STRAP NO STRAP

Bleaching TrayOther

U L

DENTURE

Occlusion RimCustom TrayOther

U L

PARTIAL

Standard CRCOPremium CRCOwith Occlusion RimAcrylic PartialFlipperSemi PrecisionNew Partial to fit Crown or Bridge

U L

ANTERIOR SET-UPIdeal Characterized Study Model

CHECKLIST

Midline Marked High Lip LineProper Lip Support Emergency (Spare Denture)

Name/Identifier in Appliance

EconomyStandardPremium

U L

Shade

Brand

Mould

ACRYLIC SHADE

Standard EthnicOther MILD MODERATE HEAVY

PARTIAL DESIGN

Lab SelectPalatal StrapHorseshoeDouble Palatal BarLingual BarLingual ApronDouble Bar

U L

Lab Design Complete

MAJOR CONNECTORS

Lab SelectMeshMesh with PostsMetal Pads With PostsOpen Face DummyMetal DummyThermo Flex Dummy

U LSADDLE AREAS

GoldVisiClear™Valplast®

Flexible

U L

TOOTH #

Lab SelectMesial RestDistal RestCingulum RestInverted V RestChannel Rest

U LREST AREAS TOOTH #

Lab SelectSuprabulgeInfrabulge (I-Bar)Flexible Tooth ShadeClear Cosmetic Clasp

U LCLASP OPTIONS TOOTH #

SPLINT

DENTURE & TEETH

Laboratory Procedure Authorization | DR SIGNATURE REQUIREDREMOVABLE PRESCRIPTION FORM

INSTRUCTIONS

R L

UPPER

LOWER

800.259.3717www.dentalservices.net

TEETH

PT NAME

FEMALE MALE

DUE DATE FINISH TRY IN CALL MEENCLOSED WITH CASE: Model BiteArticulator ImpressionsMetal Trays Teeth Photo (Preferred)Shade Tab Other

DR NAME AGEFIRST

LAST

F RR1 01

DR LICENSE #DO YOU NEED? Shipping Boxes

Shipping LabelsFixed Removable

Ortho/SleepStandardImplant

RXS:

TERMS: Net 15th of month. A finance charge of 1½% per month (18% annual) will be added to past due invoices

Cosmetic ValueDR SIGNATURE Local (WHERE AVAILABLE)

For Warranty Information: Please review the DSG Warranty Policy at www.dentalservices.net/dsg-warranty

ADDRESS

PHONESTATECITY ZIP