denture essential premium artisan
TRANSCRIPT
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