*Yellow fields are required Dr Address City State Zip Phone Shade Tab Type .... VITA 3D VITA Lumin Chromascope Other Other Shade Prep Shade Special Instructions Ideal Tooth Length 6  mm     7   mm 8  mm     9   mm 10 mm     11 mm 12 mm Smile Catalog Smile Type Soft Tissue Model If you would like to include a photos you may attach them below. If you have more than 5 images, please attach them as a zipped file. Please keep in mind the larger the file size, the longer it will take for the form to send. Need help?

Patient    Male    Female    Return Date Time Seat Date     Time Articulator        Opposing Model        Stick Bite Bite   Type CO     CR    NM # of Impressions Working Impression Opposing Impression Temp Impression Pre Op Model    Shade Tab    Facebow            Type Natural Wax           Beige Wax        Correct Malalignment               Contour Like: Close Spaces                                   Study Model Increase Length                              Temp Model Color Change                            Other PFM     Tooth #      Stained       Stained/Layered       Complex Empress     Tooth #           Stained  Stained/Layered  E Max     Tooth #           Stained       Stained/Layered                  Feldspathic Vaneer Pressed to Zerconium (PFZ)    Tooth #           Stained       Stained/Layered       Full Contour Zicronium (FCZ)     Tooth #            Polished       Stained       Full Cast Gold     Tooth #            White High Noble         Yellow High Noble             Other Temporary     Tooth #               Luxitemp          Acrylic             Gradia Gradia Crown     Tooth #               Metal Reinforced       Fiber Reinforced No Visible Metal Metal Lingual Band w/ Metal Porcelain Junction Buccal Metal Lingual Band w/Precelain Butt Margin      (Shoulder or Deep Schampfer) 2/3 Metal Occlusal 360 Metal Collar Other Hygenic Ridge Lap Ovate Modified Ridge Lap

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