Reserved AppointmentsPhase 1 Pre-Diagnostic (bite shell & abutment guide)
Doctor: ________________________ Surgery Date: _________ Time _________
Address: __________________________________________________________
Phase 2 Try-In OPTIONAL (Bar w/ teeth set in wax) NOT NEEDED
Doctor: ________________________Try-In Date: ___________ Time _________
Address: __________________________________________________________
Phase 2 Provisional Delivery
Doctor: ________________________ Delivery Date: ________ Time: _________
Address: __________________________________________________________
Next Day Hybrid Rx
O: 561.272.6662 | E: [email protected]
Dental Laboratory
601 North Congress Ave,Ste 111A,Delray Beach, FL 33445P: 561.272.6662
Phase 1 - Reservation & Work Instructions before Surgery
Specialist & Patient InformationSurgical Dr. Name: ________________________________ Phone: ___________
Signature: ______________________________ License #: __________________The person signing this work order accepts responsibility for payment and agrees to pay all collection costs
including attorney’s fees. A 1 ½ % (18%vr.) finance charge will be added to all balances due over 30 days.
I am a surgical specialist operating in a surgical office I am a surgical specialist operating in a restorative office I am a restorative specialist operating in a restorative practice
Patient Name: __________________________ Sex: Male Female
Chairside ServicePhase 1 Pre-Diagnostic Assistance (Anytime)
Surgical Appointment Assistance (AM Only) Phase 2 Provisional Delivery Assistance (3:00 PM or Later) No Service Requested
Pre-Surgical Phase 1 Items Sent (enclosures)Upper & Lower Study Cast (Required) Kois Dental Facial Analyser
Centric Relation Bite (Required) Pictures
Screw-Retained Restorative SolutionProvisional Options (24 Hours) Final Options (48 Hour) TBS Hybrid Provisional TBS Final Hybrid Printed Hybrid Provisional BioLogic Final Hybrid Printed Crown & Bridge Provisional
(crown contours with no pink tissue)
Special Instructions
Page 1
Tooth InstructionsLength X Width of Centrals __________X__________
Midline Shift ____________mm L or R
Move Max Incisal Edge __________mm Up or Down
Move Max Incisal Edge __________mm Facially or Paletaly
Procline Recline
Next Day Hybrid Rx
O: 561.272.6662 | E: [email protected]
Dental Laboratory
601 North Congress Ave,Ste 111A,Delray Beach, FL 33445P: 561.272.6662
Specialist & Patient InformationSurgical Dr. Name: __________________________________
Restorative Dr. Name: _______________________________
Phase 2 - Work Instructions for Provisional after Surgery
Day of Surgery EnclosuresMaster Implant Impression (required)
Filled Vertical Bite Shell (required) Centric Relation Bite with bite shell in place (required) Mush Bite (ONLY when shell can’t be used)
Implant SitesImplant Manufacturer Connection Platform
Site Type Diameter
1. _________________ ___________ __________
2. _________________ ___________ __________
3. _________________ ___________ __________
4. _________________ ___________ __________
5. _________________ ___________ __________
6. _________________ ___________ __________
Implant Components Party Supplying PartsManufacturer Connection Type QTY Surgical Restorative Lab
Analog ___________ _____________ ___
Cylinder ___________ _____________ ___
Screw ___________ _____________ ___
Impression ___________ _____________ ___Transfer
Shade_______Vita 16 Shades Only
Special Instructions
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