prosthetic & orthodontic work fileskele plate skele plate repair/addition/reline: upper denture...

Part Upper Part LowerFull Upper Full Lower

Permanent Temporary

Maurice Hood Dental Laboratory Ltd, Houghton Street, Oldbury, West Midlands, B69 2BBTel: 0121 544 8855 - email: info@mauricehood.co.uk - web: www.mauricehood.co.uk

Job Number: (Lab Use Only)

Appointment Type: Date Required:

Special Tray / Bite

Try-in

Re-try

Fit / Finish

Patient Age: Shade:

Please give full details and dates of work required now plus anyplanned extractions or implants to be placed. For temporary dentureswhat permanent restoration is likely to be required:

Female:Male: Notation:

32 3837363534333148 47 414243444546

28272625242321 2211121314151618 17

Dentist:

Dentist Email:

Patient Name:

Practice:Prosthetic & Orthodontic Work

Rubber ImpAlginate ImpStudy Model(s)Old crown for shade match

Bite RegistrationPhotograph(s) emailedComponentsFace Bow

Other:

Enclosures:

RESTORATION OPTIONS:

Type of Prosthesis

OrthoBite Raiser (Hard)Bite Raiser (Soft)Bleaching Tray

ORTHODONTIC/MOUTHGUARD:

Signed:ENCLOSURE REVIEW (lab use):

Upper LowerUpper LowerUpper LowerUpper Lower

MouthguardColour

Upper Lower

Chrome UpperChrome LowerFlexible DentSpecial Tray

FullFullUpper LowerUpper Lower

Skele PlateSkele Plate

REPAIR/ADDITION/RELINE:Upper DentureLower Denture

RepairRepair

Addition RelineAddition Reline

Magnet RetainedTelescopic RetainedMilled CrownsImmediate extractions plannedSpace for implant / bone augmentDenar mounting