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Dr. Phone #
Patient
Deliver by 5 p.m. on
Rx
LABORATORY USE ONLY
By ________ Mail ________
GLIDEWELL LABORATORIES4141 MACARTHUR BLVD. • NEWPORT BEACH, CA 92660
800-854-7256 • Toll-free fax 800-411-9722
• FIXED RESTORATIVE RX • Dr. Name
Dr. Account #
Address/E-mail
PORCELAIN FUSED TO METAL ❑ Non-Precious* ❑ Noble ❑ White High Noble ❑ Captek YHN ❑OcclusalGold YHN
*Standard unless specified otherwise
COMPOSITES❑Premise Indirect* ❑Sinfony
❑Fiber Reinforcement
Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑Photos Other:
01-421-0908fixed
See Reverse For In-Lab Times
IMPLANT ABUTMENTS
❑Titanium* ❑Zirconia
Specify system: ❑3i ❑Nobel Biocare ❑Straumann ❑Zimmer
Specify brand:___________________ Specify diameter on Rx
PROVISIONALS ❑BioTemps ❑Transition C&B
Abutment #s________________________________
Pontic #(s)___________________ Total units_____
❑Splinted* ❑Individual units
Reinforcement: ❑None ❑Wire* ❑Fiber ❑Metal
Amount of prep reduction: ❑1mm* ❑2mm
❑Perio treatment: Prepare tooth below gingival
on tooth #(s) ____________ by __________mm
❑Pontic site healing: Prepare ovate socket
on tooth #(s) ____________ by __________mm
IF NO OCCLUSAL CLEARANCE
❑Call Doctor
❑Spot Opposing
❑Metal Occlusion ❑Yes ❑No
Would you like this to be a permanent note in
your master file?
Copyright ©2008 Glidewell Laboratories
FULL-CAST RESTORATIONS
❑ Noble-Cast 45 YN (40%Au) ❑ Non-Precious ❑ Noble-Cast 60* YHN (57.5%Au) ❑ White Noble ❑ Noble-Cast 67 YHN (64%Au) ❑WHN (45%Au) ❑ OcclusalGold YHN (73.8%Au) ❑ Post & Core ❑ JRVT YHN (77%Au)
*Standard unless specified otherwise
*Standard unless specified otherwise
*Standard unless specified otherwise
(First) (Last)
Signature ______________________________________________________ License # ______________________________
❑ check here to manufacture ceramics or full-cast using cad/cam
PORCELAIN FUSED TO ZIRCONIA❑Prismatik Clinical Zirconia* ❑Lava ❑Cercon Procera: ❑Zirconia ❑Bridge Zirconia
ALL-CERAMICS❑Vivaneers No-Prep Veneers* ❑IPS e.max CAD* ❑IPS Empress Veneer ❑IPS e.max Press ❑IPS Empress ❑Procera Alumina❑IPS Empress CAD
Indicate stump or present tooth shade for all-ceramics
PONTIC DESIGN
FINAL CERAMIC SHADE
OCCLUSAL STAINING ❑ None ❑ Light* ❑ Medium ❑ Dark
❑ ❑ ❑* ❑ ❑
MARGIN/METAL DESIGN
❑❑❑❑* ❑
Indicate Shade Here
❑❑❑* ❑
PRESENT TOOTH OR STUMP SHADE
Indicate Shade Here
If No Occlusal Clearance
❑Call doctor ❑Spot opposing
❑Metal occlusion ❑Metal island
❑Make this a permanent note in my master file
Labial Butt 360° Butt Junction Junction ❑ ❑ ❑* ❑
Dr. __________________________________________________________
Patient _______________________________________________________
Date Sent _____________________________________________________
Due Date _____________________________________________________
Enclosed with case: q Impressions q Models q Bite q Photos q Partial Other:____________
Dr. Phone #
Patient
Deliver by 5 p.m. on
Rx
LABORATORY USE ONLY
By ________ Mail ________
GLIDEWELL LABORATORIES4141 MACARTHUR BLVD. • NEWPORT BEACH, CA 92660
800-854-7256 • Toll-free fax 800-411-9722
• FIXED RESTORATIVE RX • Dr. Name
Dr. Account #
Address/E-mail
PORCELAIN FUSED TO METAL ❑ Non-Precious* ❑ Noble ❑ White High Noble ❑ Captek YHN ❑OcclusalGold YHN
*Standard unless specified otherwise
COMPOSITES❑Premise Indirect* ❑Sinfony
❑Fiber Reinforcement
Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑Photos Other:
01-421-0908fixed
See Reverse For In-Lab Times
IMPLANT ABUTMENTS
❑Titanium* ❑Zirconia
Specify system: ❑3i ❑Nobel Biocare ❑Straumann ❑Zimmer
Specify brand:___________________ Specify diameter on Rx
PROVISIONALS ❑BioTemps ❑Transition C&B
Abutment #s________________________________
Pontic #(s)___________________ Total units_____
❑Splinted* ❑Individual units
Reinforcement: ❑None ❑Wire* ❑Fiber ❑Metal
Amount of prep reduction: ❑1mm* ❑2mm
❑Perio treatment: Prepare tooth below gingival
on tooth #(s) ____________ by __________mm
❑Pontic site healing: Prepare ovate socket
on tooth #(s) ____________ by __________mm
IF NO OCCLUSAL CLEARANCE
❑Call Doctor
❑Spot Opposing
❑Metal Occlusion ❑Yes ❑No
Would you like this to be a permanent note in
your master file?
Copyright ©2008 Glidewell Laboratories
FULL-CAST RESTORATIONS
❑ Noble-Cast 45 YN (40%Au) ❑ Non-Precious ❑ Noble-Cast 60* YHN (57.5%Au) ❑ White Noble ❑ Noble-Cast 67 YHN (64%Au) ❑WHN (45%Au) ❑ OcclusalGold YHN (73.8%Au) ❑ Post & Core ❑ JRVT YHN (77%Au)
*Standard unless specified otherwise
*Standard unless specified otherwise
*Standard unless specified otherwise
(First) (Last)
Signature ______________________________________________________ License # ______________________________
❑ check here to manufacture ceramics or full-cast using cad/cam
PORCELAIN FUSED TO ZIRCONIA❑Prismatik Clinical Zirconia* ❑Lava ❑Cercon Procera: ❑Zirconia ❑Bridge Zirconia
ALL-CERAMICS❑Vivaneers No-Prep Veneers* ❑IPS e.max CAD* ❑IPS Empress Veneer ❑IPS e.max Press ❑IPS Empress ❑Procera Alumina❑IPS Empress CAD
Indicate stump or present tooth shade for all-ceramics
PONTIC DESIGN
FINAL CERAMIC SHADE
OCCLUSAL STAINING ❑ None ❑ Light* ❑ Medium ❑ Dark
❑ ❑ ❑* ❑ ❑
MARGIN/METAL DESIGN
❑❑❑❑* ❑
Indicate Shade Here
❑❑❑* ❑
PRESENT TOOTH OR STUMP SHADE
Indicate Shade Here
If No Occlusal Clearance
❑Call doctor ❑Spot opposing
❑Metal occlusion ❑Metal island
❑Make this a permanent note in my master file
Labial Butt 360° Butt Junction Junction ❑ ❑ ❑* ❑
TERMS: 2% Monthly Service Charge Over 30 Days. Customer agrees to pay full cost of collection plus attorney fees and court costs.
7602 Talbert Avenue, Suite EHuntington Beach, CA 92648
(714) 842-0466 Fax (714) [email protected]
www.hogandentallab.com
OGAN ENTAL
HDLAB USE ONLY
CASE PAN #
SHIP DATE
DENTIST
ANTERIOR METAL DESIGNq No Metal Showing
q Lingual Metal Collar
q Metal Lingual
SHADE INSTRUCTIONS
PONTIC DESIGN ANTERIOR METAL DESIGN
POSTERIOR METAL DESIGN OCCLUSALSTAINING
INSTRUCTION FOR BUCCAL MARGIN
� � � � � � �
� � � �� �
� None
� Light
� Medium
� Dark
� Metal hairline or ________mm on buccal� Metal-porcelain junction margin� Porcelain butt margin (90° shoulder required)
ENCLOSED WITH CASE
___ Impression ___ Models ___ Bite
___ Articulator ___ Crown/Bridge
Other _____________________________
LABORATORY PROCEDURE AUTHORIZATIONPLEASE WRITE CLEARLY TO ENSURE PROPER BILLING & SHIPPING
©2007 Glidewell Laboratories
�
�
�
�
Full coverage
Lingual metal collar
Excluding buccal cusp
Including buccal cusp
01-1125-0507
4141 MacArthur Blvd. • Newport Beach, CA 92660Toll-free 800-787-4736 • fax 800-579-8233
Date Sent: ___________________
Date Due: ___________________
Patient/ID: _______________________Lab: ______________________________________
Address: __________________________________
City: ______________________________________ State: _____ Zip: ___________
xSPECIFIC INSTRUCTIONS
TOOTHNUMBER
Signature: ________________________________ Date: ____________I verify that a signed prescription from a licensed dentist is on file for the restoration.
� Prismatik CZ� Lava Zirconia
Dr. Zip Code: ______________(3M Required)
� Cercon Zirconia� Procera Zirconia� Procera Zirconia bridge� Procera Zirconia
Custom Implant Abutment
� IPS Empress� IPS e.max� Wol-Ceram Alumina� Procera Alumina
� BioTemps� Transition C&BAbutment #s ___________________________________Pontic #s _______________Total Units ______________
� Non-precious� Noble (Semi-precious)� White High Noble� Captek YHN� Yellow High Noble � Procera Titanium
Custom Implant Abutment
PROVISIONALS
ZIRCONIA
ALL-CERAMICS
PORCELAIN TO METAL
INDICATE CORE SHADE BESIDE TOOTH # BELOW
� Coping(s)/Substructure(s) � Unfinished Crown(s) � Finished Crown(s)� Build-up coping(s)/substructure(s) for porcelain support
GLIDEWELLLABORATORIES
SHADE INSTRUCTIONS
PONTIC DESIGN ANTERIOR METAL DESIGN
POSTERIOR METAL DESIGN OCCLUSALSTAINING
INSTRUCTION FOR BUCCAL MARGIN
� � � � � � �
� � � �� �
� None
� Light
� Medium
� Dark
� Metal hairline or ________mm on buccal� Metal-porcelain junction margin� Porcelain butt margin (90° shoulder required)
ENCLOSED WITH CASE
___ Impression ___ Models ___ Bite
___ Articulator ___ Crown/Bridge
Other _____________________________
LABORATORY PROCEDURE AUTHORIZATIONPLEASE WRITE CLEARLY TO ENSURE PROPER BILLING & SHIPPING
©2007 Glidewell Laboratories
�
�
�
�
Full coverage
Lingual metal collar
Excluding buccal cusp
Including buccal cusp
01-1125-0507
4141 MacArthur Blvd. • Newport Beach, CA 92660Toll-free 800-787-4736 • fax 800-579-8233
Date Sent: ___________________
Date Due: ___________________
Patient/ID: _______________________Lab: ______________________________________
Address: __________________________________
City: ______________________________________ State: _____ Zip: ___________
xSPECIFIC INSTRUCTIONS
TOOTHNUMBER
Signature: ________________________________ Date: ____________I verify that a signed prescription from a licensed dentist is on file for the restoration.
� Prismatik CZ� Lava Zirconia
Dr. Zip Code: ______________(3M Required)
� Cercon Zirconia� Procera Zirconia� Procera Zirconia bridge� Procera Zirconia
Custom Implant Abutment
� IPS Empress� IPS e.max� Wol-Ceram Alumina� Procera Alumina
� BioTemps� Transition C&BAbutment #s ___________________________________Pontic #s _______________Total Units ______________
� Non-precious� Noble (Semi-precious)� White High Noble� Captek YHN� Yellow High Noble � Procera Titanium
Custom Implant Abutment
PROVISIONALS
ZIRCONIA
ALL-CERAMICS
PORCELAIN TO METAL
INDICATE CORE SHADE BESIDE TOOTH # BELOW
� Coping(s)/Substructure(s) � Unfinished Crown(s) � Finished Crown(s)� Build-up coping(s)/substructure(s) for porcelain support
GLIDEWELLLABORATORIES
No Metal Showing
Age
_______M / F
OCCLUSAL STAININGq None q Lightq Medium q Dark
POSTERIOR METAL DESIGN
PONTIC DESIGN
OTHER SERVICESq Porcelain Labial Butt Margin (shoulder required)q Metal Try Inq Bisque Bake Try Inq Removal Buttonq Post: Separate / Fixed / Castq Future R.P.D. Rest Mesial, Distal, Cingulumq Partial Adaptionq Precision Attachment M/Fq ERA Attachmentq Splint
PORCELAIN FUSED TO METALHigh Noble Alloys* Noble Alloys* Other Alloysq 40% White Gold q 25% Palladium q Non-Precious q 80% Palladium q No - Nickel* *Additional charges apply
FULL METALq 63% Yellow Gold (HN)*q 2% Yellow Gold (N)*q 80% Palladium (N)*q Non-Preciousq No - Nickel*
IPS E.MAX®
q Veneer q Inlay / Onlay q IPS E.max® Press/Layering Crown
ZIRCONIAq Zirconia with Porcelain Overlay q Lavaq BruxZir® Solid Zirconia (Authorized BruxZir® Laboratory)
Shoulder required • Indicate stump shade
LABORATORY
q Separate Crown
q Bridge
Dr. Phone #
Patient
Deliver by 5 p.m. on
Rx
LABORATORY USE ONLY
By ________ Mail ________
GLIDEWELL LABORATORIES4141 MACARTHUR BLVD. • NEWPORT BEACH, CA 92660
800-854-7256 • Toll-free fax 800-411-9722
• FIXED RESTORATIVE RX • Dr. Name
Dr. Account #
Address/E-mail
PORCELAIN FUSED TO METAL ❑ Non-Precious* ❑ Noble ❑ White High Noble ❑ Captek YHN ❑OcclusalGold YHN
*Standard unless specified otherwise
COMPOSITES❑Premise Indirect* ❑Sinfony
❑Fiber Reinforcement
Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑Photos Other:
01-421-0908fixed
See Reverse For In-Lab Times
IMPLANT ABUTMENTS
❑Titanium* ❑Zirconia
Specify system: ❑3i ❑Nobel Biocare ❑Straumann ❑Zimmer
Specify brand:___________________ Specify diameter on Rx
PROVISIONALS ❑BioTemps ❑Transition C&B
Abutment #s________________________________
Pontic #(s)___________________ Total units_____
❑Splinted* ❑Individual units
Reinforcement: ❑None ❑Wire* ❑Fiber ❑Metal
Amount of prep reduction: ❑1mm* ❑2mm
❑Perio treatment: Prepare tooth below gingival
on tooth #(s) ____________ by __________mm
❑Pontic site healing: Prepare ovate socket
on tooth #(s) ____________ by __________mm
IF NO OCCLUSAL CLEARANCE
❑Call Doctor
❑Spot Opposing
❑Metal Occlusion ❑Yes ❑No
Would you like this to be a permanent note in
your master file?
Copyright ©2008 Glidewell Laboratories
FULL-CAST RESTORATIONS
❑ Noble-Cast 45 YN (40%Au) ❑ Non-Precious ❑ Noble-Cast 60* YHN (57.5%Au) ❑ White Noble ❑ Noble-Cast 67 YHN (64%Au) ❑WHN (45%Au) ❑ OcclusalGold YHN (73.8%Au) ❑ Post & Core ❑ JRVT YHN (77%Au)
*Standard unless specified otherwise
*Standard unless specified otherwise
*Standard unless specified otherwise
(First) (Last)
Signature ______________________________________________________ License # ______________________________
❑ check here to manufacture ceramics or full-cast using cad/cam
PORCELAIN FUSED TO ZIRCONIA❑Prismatik Clinical Zirconia* ❑Lava ❑Cercon Procera: ❑Zirconia ❑Bridge Zirconia
ALL-CERAMICS❑Vivaneers No-Prep Veneers* ❑IPS e.max CAD* ❑IPS Empress Veneer ❑IPS e.max Press ❑IPS Empress ❑Procera Alumina❑IPS Empress CAD
Indicate stump or present tooth shade for all-ceramics
PONTIC DESIGN
FINAL CERAMIC SHADE
OCCLUSAL STAINING ❑ None ❑ Light* ❑ Medium ❑ Dark
❑ ❑ ❑* ❑ ❑
MARGIN/METAL DESIGN
❑❑❑❑* ❑
Indicate Shade Here
❑❑❑* ❑
PRESENT TOOTH OR STUMP SHADE
Indicate Shade Here
If No Occlusal Clearance
❑Call doctor ❑Spot opposing
❑Metal occlusion ❑Metal island
❑Make this a permanent note in my master file
Labial Butt 360° Butt Junction Junction ❑ ❑ ❑* ❑
360° Metal Margin Thin, 0.5, 1.0 mm
Dr. Phone #
Patient
Deliver by 5 p.m. on
Rx
LABORATORY USE ONLY
By ________ Mail ________
GLIDEWELL LABORATORIES4141 MACARTHUR BLVD. • NEWPORT BEACH, CA 92660
800-854-7256 • Toll-free fax 800-411-9722
• FIXED RESTORATIVE RX • Dr. Name
Dr. Account #
Address/E-mail
PORCELAIN FUSED TO METAL ❑ Non-Precious* ❑ Noble ❑ White High Noble ❑ Captek YHN ❑OcclusalGold YHN
*Standard unless specified otherwise
COMPOSITES❑Premise Indirect* ❑Sinfony
❑Fiber Reinforcement
Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑Photos Other:
01-421-0908fixed
See Reverse For In-Lab Times
IMPLANT ABUTMENTS
❑Titanium* ❑Zirconia
Specify system: ❑3i ❑Nobel Biocare ❑Straumann ❑Zimmer
Specify brand:___________________ Specify diameter on Rx
PROVISIONALS ❑BioTemps ❑Transition C&B
Abutment #s________________________________
Pontic #(s)___________________ Total units_____
❑Splinted* ❑Individual units
Reinforcement: ❑None ❑Wire* ❑Fiber ❑Metal
Amount of prep reduction: ❑1mm* ❑2mm
❑Perio treatment: Prepare tooth below gingival
on tooth #(s) ____________ by __________mm
❑Pontic site healing: Prepare ovate socket
on tooth #(s) ____________ by __________mm
IF NO OCCLUSAL CLEARANCE
❑Call Doctor
❑Spot Opposing
❑Metal Occlusion ❑Yes ❑No
Would you like this to be a permanent note in
your master file?
Copyright ©2008 Glidewell Laboratories
FULL-CAST RESTORATIONS
❑ Noble-Cast 45 YN (40%Au) ❑ Non-Precious ❑ Noble-Cast 60* YHN (57.5%Au) ❑ White Noble ❑ Noble-Cast 67 YHN (64%Au) ❑WHN (45%Au) ❑ OcclusalGold YHN (73.8%Au) ❑ Post & Core ❑ JRVT YHN (77%Au)
*Standard unless specified otherwise
*Standard unless specified otherwise
*Standard unless specified otherwise
(First) (Last)
Signature ______________________________________________________ License # ______________________________
❑ check here to manufacture ceramics or full-cast using cad/cam
PORCELAIN FUSED TO ZIRCONIA❑Prismatik Clinical Zirconia* ❑Lava ❑Cercon Procera: ❑Zirconia ❑Bridge Zirconia
ALL-CERAMICS❑Vivaneers No-Prep Veneers* ❑IPS e.max CAD* ❑IPS Empress Veneer ❑IPS e.max Press ❑IPS Empress ❑Procera Alumina❑IPS Empress CAD
Indicate stump or present tooth shade for all-ceramics
PONTIC DESIGN
FINAL CERAMIC SHADE
OCCLUSAL STAINING ❑ None ❑ Light* ❑ Medium ❑ Dark
❑ ❑ ❑* ❑ ❑
MARGIN/METAL DESIGN
❑❑❑❑* ❑
Indicate Shade Here
❑❑❑* ❑
PRESENT TOOTH OR STUMP SHADE
Indicate Shade Here
If No Occlusal Clearance
❑Call doctor ❑Spot opposing
❑Metal occlusion ❑Metal island
❑Make this a permanent note in my master file
Labial Butt 360° Butt Junction Junction ❑ ❑ ❑* ❑
SHADE
SHADE INSTRUCTIONS
PONTIC DESIGN ANTERIOR METAL DESIGN
POSTERIOR METAL DESIGN OCCLUSALSTAINING
INSTRUCTION FOR BUCCAL MARGIN
� � � � � � �
� � � �� �
� None
� Light
� Medium
� Dark
� Metal hairline or ________mm on buccal� Metal-porcelain junction margin� Porcelain butt margin (90° shoulder required)
ENCLOSED WITH CASE
___ Impression ___ Models ___ Bite
___ Articulator ___ Crown/Bridge
Other _____________________________
LABORATORY PROCEDURE AUTHORIZATIONPLEASE WRITE CLEARLY TO ENSURE PROPER BILLING & SHIPPING
©2007 Glidewell Laboratories
�
�
�
�
Full coverage
Lingual metal collar
Excluding buccal cusp
Including buccal cusp
01-1125-0507
4141 MacArthur Blvd. • Newport Beach, CA 92660Toll-free 800-787-4736 • fax 800-579-8233
Date Sent: ___________________
Date Due: ___________________
Patient/ID: _______________________Lab: ______________________________________
Address: __________________________________
City: ______________________________________ State: _____ Zip: ___________
xSPECIFIC INSTRUCTIONS
TOOTHNUMBER
Signature: ________________________________ Date: ____________I verify that a signed prescription from a licensed dentist is on file for the restoration.
� Prismatik CZ� Lava Zirconia
Dr. Zip Code: ______________(3M Required)
� Cercon Zirconia� Procera Zirconia� Procera Zirconia bridge� Procera Zirconia
Custom Implant Abutment
� IPS Empress� IPS e.max� Wol-Ceram Alumina� Procera Alumina
� BioTemps� Transition C&BAbutment #s ___________________________________Pontic #s _______________Total Units ______________
� Non-precious� Noble (Semi-precious)� White High Noble� Captek YHN� Yellow High Noble � Procera Titanium
Custom Implant Abutment
PROVISIONALS
ZIRCONIA
ALL-CERAMICS
PORCELAIN TO METAL
INDICATE CORE SHADE BESIDE TOOTH # BELOW
� Coping(s)/Substructure(s) � Unfinished Crown(s) � Finished Crown(s)� Build-up coping(s)/substructure(s) for porcelain support
GLIDEWELLLABORATORIES
IMPLANTS
Abutment: q Titanium q Zirconia q Other:__________
Specify system: q Nobel BioCare q Zimmer q 3i
q Astra q Dentsply q Straumann
q Other:__________ Specify diameter on Rx
PONTIC DESIGN
Rx
LABORATORY USE ONLY
By _____________ Mail ______________
FINAL CERAMIC SHADE PORCELAIN FUSED TO METAL ❑ Non-Precious* ❑ Noble ❑ WHN ❑ Captek YHN ❑OcclusalGold YHN
COMPOSITE RESTORATIONS ❑Composite ❑Fiber Reinforcement
PLAYSAFE MOUTHGUARDS❑ Jr ❑ Lt ❑ Lt Pro ❑ Med* ❑ Hvy ❑ Hvy Pro
❑ Helmet Strap Specify color(s) on Rx
❑Name ________________________________________________
VITALLIUM METAL PARTIALS❑Vitallium 2000* ❑Vitallium 2000 Plus ❑tcs/Vitallium ❑Valplast/Vitallium❑Titanium ❑Wironium ❑tcs/Wironium ❑ Lab select complete design❑Frame try-in ❑Frame w/occlus. rim ❑Frame w/setup try-in ❑Finish
CROWN & PARTIAL COMBINATION CASES
❑Future Partial: ___Vitallium ___Valplast ___tcs ___Attachments ❑ Fabricate RPD to fit restoration
MAJOR CONNECTOR
Maxillary Mandibular
❑Lab select ❑ Lab select
❑ _____________ ❑ ______________
Rest Areas Tooth #
❑Lab select ________________
❑ _____________ ________________
OCCLUSAL STAINING ❑ None ❑ Light* ❑ Medium ❑ Dark
GL-421-1011
SNORING/SLEEP APNEA APPLIANCESUpper and lower models with protrusive bite required
❑ Silent Nite sl* ❑ TAP ❑ TAP 3 ❑ EMA
INCLUSIVE CUSTOM ABUTMENTS❑Titanium* ❑Zirconia w/ Ti-Insert ❑All-Zirconia
Specify implant system, brand and diameter on Rx IF NO OCCLUSAL CLEARANCE
❑Call doctor ❑Spot opposing
❑Metal occlusion ❑Metal island
❑Make this a permanent note in my master file
©2011 Glidewell Laboratories
FULL-CAST RESTORATIONS ❑ Noble-Cast 45 YN (40% Au) ❑ Non-Precious
❑ Noble-Cast 60YHN (57.5% Au)* ❑ White Noble
❑ Noble-Cast 67 YHN (64% Au) ❑ WHN (45% Au)
❑ OcclusalGold YHN (73.8% Au) ❑ Post & Core
❑ JRVT YHN (77% Au)
ZIRCONIA RESTORATIONS❑ BruxZir Solid Zirconia ❑ Prismatik CZ* ❑ Lava ❑ NobelProcera Zirconia
❑ ❑ ❑* ❑ ❑
Clasp Options Tooth#
❑Lab select _____________________
❑Metal _____________________
❑Estheticlasp _____________________
❑ Thermoflex _____________________
❑ _______________ _____________________
MARGIN AND METAL DESIGN
❑❑❑❑* ❑
DENTURES/FLEXIBLE PARTIALS❑ Flipper ❑ Denture ❑ Valplast ❑ tcs ❑ Dupe denture❑ Custom tray ❑ Occlusion rim ❑ Wax setup try-in ❑ Finish
❑Premium Brand Teeth (extra charge applies)
Shade ________ Brand _______________ Mould ________
❑Kenson Teeth (included at no extra charge)
Shade ______________ Mould _______________________
Acrylic shade: ❑ Ethnic: Lt ❑ Med ❑ Dk ❑Acrylic tabs available: G1 (standard) G2 G3 G4
❑ Name on appliance _________________________________________ (Additional charge)
Tooth setup ❑ Ideal ❑ Characterized ❑ Study model❑ Male ❑ Female Age ________
PROVISIONAL RESTORATIONS
❑BioTemps ❑Transition C&B ❑Smile Transitions
Abutment #s________________________________
Pontic #(s)___________________ Total units_____
❑Splinted* ❑Cement-on implant❑Individual units ❑Screw-retained implant
Reinforcement: ❑None ❑Wire* ❑Fiber ❑Metal
Amount of prep reduction: ❑1 mm* ❑2 mm
❑Perio treatment: Prepare tooth below gingival
on tooth #(s) ____________ by __________mm
❑Pontic site healing: Prepare ovate socket
on tooth #(s) ____________ by __________mm *Standard unless specified otherwise
Indicate Shade Here
Signature _________________________________________________________ License # _____________________________(see reverse for limited warranty details)
❑ Check here to manufacture ceramics or full-cast using CAd/CAM
❑❑❑* ❑
NIGHTGUARDS/BITE SPLINTS ❑ Upper ❑ Lower
❑ Comfort H/S (hard/soft)* ❑ Comfort (hard) ❑ Semi-Hard EVA ❑ Soft EVA ❑ Astron CLEARsplint ❑ Processed Acrylic
ALL-CERAMIC RESTORATIONS ❑IPS e.max CAD* (Posterior) ❑IPS e.max veneer
❑IPS e.max Press* (Anterior)
❑Vivaneers No-Prep Veneers* ❑IPS Empress
Indicate stump or present tooth shade for all-ceramics
PRESENT TOOTH OR STUMP SHADE
Indicate Shade Here
Labial Butt 360° Butt Junction Junction ❑ ❑ ❑* ❑
GLIDEWELL LABORATORIES4141 MacArthur Blvd. • Newport Beach, CA 92660
800-854-7256 • Fax 800-599-9564 Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑ Photos ❑ Other: ___________________________
• UNIVERSAL Rx •
See Reverse for Working Times
Dr. Name _________________________________________________ Phone #__________________________
Acct. # ____________________________________ Patient Name ____________________________________
Address/E-mail _____________________________ Deliver by 5 p.m. on ____________________________
First Last
All Restorations Made in the USA
PONTIC DESIGN
Rx
LABORATORY USE ONLY
By _____________ Mail ______________
FINAL CERAMIC SHADE PORCELAIN FUSED TO METAL ❑ Non-Precious* ❑ Noble ❑ WHN ❑ Captek YHN ❑OcclusalGold YHN
COMPOSITE RESTORATIONS ❑Composite ❑Fiber Reinforcement
PLAYSAFE MOUTHGUARDS❑ Jr ❑ Lt ❑ Lt Pro ❑ Med* ❑ Hvy ❑ Hvy Pro
❑ Helmet Strap Specify color(s) on Rx
❑Name ________________________________________________
VITALLIUM METAL PARTIALS❑Vitallium 2000* ❑Vitallium 2000 Plus ❑tcs/Vitallium ❑Valplast/Vitallium❑Titanium ❑Wironium ❑tcs/Wironium ❑ Lab select complete design❑Frame try-in ❑Frame w/occlus. rim ❑Frame w/setup try-in ❑Finish
CROWN & PARTIAL COMBINATION CASES
❑Future Partial: ___Vitallium ___Valplast ___tcs ___Attachments ❑ Fabricate RPD to fit restoration
MAJOR CONNECTOR
Maxillary Mandibular
❑Lab select ❑ Lab select
❑ _____________ ❑ ______________
Rest Areas Tooth #
❑Lab select ________________
❑ _____________ ________________
OCCLUSAL STAINING ❑ None ❑ Light* ❑ Medium ❑ Dark
GL-421-1011
SNORING/SLEEP APNEA APPLIANCESUpper and lower models with protrusive bite required
❑ Silent Nite sl* ❑ TAP ❑ TAP 3 ❑ EMA
INCLUSIVE CUSTOM ABUTMENTS❑Titanium* ❑Zirconia w/ Ti-Insert ❑All-Zirconia
Specify implant system, brand and diameter on Rx IF NO OCCLUSAL CLEARANCE
❑Call doctor ❑Spot opposing
❑Metal occlusion ❑Metal island
❑Make this a permanent note in my master file
©2011 Glidewell Laboratories
FULL-CAST RESTORATIONS ❑ Noble-Cast 45 YN (40% Au) ❑ Non-Precious
❑ Noble-Cast 60YHN (57.5% Au)* ❑ White Noble
❑ Noble-Cast 67 YHN (64% Au) ❑ WHN (45% Au)
❑ OcclusalGold YHN (73.8% Au) ❑ Post & Core
❑ JRVT YHN (77% Au)
ZIRCONIA RESTORATIONS❑ BruxZir Solid Zirconia ❑ Prismatik CZ* ❑ Lava ❑ NobelProcera Zirconia
❑ ❑ ❑* ❑ ❑
Clasp Options Tooth#
❑Lab select _____________________
❑Metal _____________________
❑Estheticlasp _____________________
❑ Thermoflex _____________________
❑ _______________ _____________________
MARGIN AND METAL DESIGN
❑❑❑❑* ❑
DENTURES/FLEXIBLE PARTIALS❑ Flipper ❑ Denture ❑ Valplast ❑ tcs ❑ Dupe denture❑ Custom tray ❑ Occlusion rim ❑ Wax setup try-in ❑ Finish
❑Premium Brand Teeth (extra charge applies)
Shade ________ Brand _______________ Mould ________
❑Kenson Teeth (included at no extra charge)
Shade ______________ Mould _______________________
Acrylic shade: ❑ Ethnic: Lt ❑ Med ❑ Dk ❑Acrylic tabs available: G1 (standard) G2 G3 G4
❑ Name on appliance _________________________________________ (Additional charge)
Tooth setup ❑ Ideal ❑ Characterized ❑ Study model❑ Male ❑ Female Age ________
PROVISIONAL RESTORATIONS
❑BioTemps ❑Transition C&B ❑Smile Transitions
Abutment #s________________________________
Pontic #(s)___________________ Total units_____
❑Splinted* ❑Cement-on implant❑Individual units ❑Screw-retained implant
Reinforcement: ❑None ❑Wire* ❑Fiber ❑Metal
Amount of prep reduction: ❑1 mm* ❑2 mm
❑Perio treatment: Prepare tooth below gingival
on tooth #(s) ____________ by __________mm
❑Pontic site healing: Prepare ovate socket
on tooth #(s) ____________ by __________mm *Standard unless specified otherwise
Indicate Shade Here
Signature _________________________________________________________ License # _____________________________(see reverse for limited warranty details)
❑ Check here to manufacture ceramics or full-cast using CAd/CAM
❑❑❑* ❑
NIGHTGUARDS/BITE SPLINTS ❑ Upper ❑ Lower
❑ Comfort H/S (hard/soft)* ❑ Comfort (hard) ❑ Semi-Hard EVA ❑ Soft EVA ❑ Astron CLEARsplint ❑ Processed Acrylic
ALL-CERAMIC RESTORATIONS ❑IPS e.max CAD* (Posterior) ❑IPS e.max veneer
❑IPS e.max Press* (Anterior)
❑Vivaneers No-Prep Veneers* ❑IPS Empress
Indicate stump or present tooth shade for all-ceramics
PRESENT TOOTH OR STUMP SHADE
Indicate Shade Here
Labial Butt 360° Butt Junction Junction ❑ ❑ ❑* ❑
GLIDEWELL LABORATORIES4141 MacArthur Blvd. • Newport Beach, CA 92660
800-854-7256 • Fax 800-599-9564 Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑ Photos ❑ Other: ___________________________
• UNIVERSAL Rx •
See Reverse for Working Times
Dr. Name _________________________________________________ Phone #__________________________
Acct. # ____________________________________ Patient Name ____________________________________
Address/E-mail _____________________________ Deliver by 5 p.m. on ____________________________
First Last
All Restorations Made in the USA
PONTIC DESIGN
Rx
LABORATORY USE ONLY
By _____________ Mail ______________
FINAL CERAMIC SHADE PORCELAIN FUSED TO METAL ❑ Non-Precious* ❑ Noble ❑ WHN ❑ Captek YHN ❑OcclusalGold YHN
COMPOSITE RESTORATIONS ❑Composite ❑Fiber Reinforcement
PLAYSAFE MOUTHGUARDS❑ Jr ❑ Lt ❑ Lt Pro ❑ Med* ❑ Hvy ❑ Hvy Pro
❑ Helmet Strap Specify color(s) on Rx
❑Name ________________________________________________
VITALLIUM METAL PARTIALS❑Vitallium 2000* ❑Vitallium 2000 Plus ❑tcs/Vitallium ❑Valplast/Vitallium❑Titanium ❑Wironium ❑tcs/Wironium ❑ Lab select complete design❑Frame try-in ❑Frame w/occlus. rim ❑Frame w/setup try-in ❑Finish
CROWN & PARTIAL COMBINATION CASES
❑Future Partial: ___Vitallium ___Valplast ___tcs ___Attachments ❑ Fabricate RPD to fit restoration
MAJOR CONNECTOR
Maxillary Mandibular
❑Lab select ❑ Lab select
❑ _____________ ❑ ______________
Rest Areas Tooth #
❑Lab select ________________
❑ _____________ ________________
OCCLUSAL STAINING ❑ None ❑ Light* ❑ Medium ❑ Dark
GL-421-1011
SNORING/SLEEP APNEA APPLIANCESUpper and lower models with protrusive bite required
❑ Silent Nite sl* ❑ TAP ❑ TAP 3 ❑ EMA
INCLUSIVE CUSTOM ABUTMENTS❑Titanium* ❑Zirconia w/ Ti-Insert ❑All-Zirconia
Specify implant system, brand and diameter on Rx IF NO OCCLUSAL CLEARANCE
❑Call doctor ❑Spot opposing
❑Metal occlusion ❑Metal island
❑Make this a permanent note in my master file
©2011 Glidewell Laboratories
FULL-CAST RESTORATIONS ❑ Noble-Cast 45 YN (40% Au) ❑ Non-Precious
❑ Noble-Cast 60YHN (57.5% Au)* ❑ White Noble
❑ Noble-Cast 67 YHN (64% Au) ❑ WHN (45% Au)
❑ OcclusalGold YHN (73.8% Au) ❑ Post & Core
❑ JRVT YHN (77% Au)
ZIRCONIA RESTORATIONS❑ BruxZir Solid Zirconia ❑ Prismatik CZ* ❑ Lava ❑ NobelProcera Zirconia
❑ ❑ ❑* ❑ ❑
Clasp Options Tooth#
❑Lab select _____________________
❑Metal _____________________
❑Estheticlasp _____________________
❑ Thermoflex _____________________
❑ _______________ _____________________
MARGIN AND METAL DESIGN
❑❑❑❑* ❑
DENTURES/FLEXIBLE PARTIALS❑ Flipper ❑ Denture ❑ Valplast ❑ tcs ❑ Dupe denture❑ Custom tray ❑ Occlusion rim ❑ Wax setup try-in ❑ Finish
❑Premium Brand Teeth (extra charge applies)
Shade ________ Brand _______________ Mould ________
❑Kenson Teeth (included at no extra charge)
Shade ______________ Mould _______________________
Acrylic shade: ❑ Ethnic: Lt ❑ Med ❑ Dk ❑Acrylic tabs available: G1 (standard) G2 G3 G4
❑ Name on appliance _________________________________________ (Additional charge)
Tooth setup ❑ Ideal ❑ Characterized ❑ Study model❑ Male ❑ Female Age ________
PROVISIONAL RESTORATIONS
❑BioTemps ❑Transition C&B ❑Smile Transitions
Abutment #s________________________________
Pontic #(s)___________________ Total units_____
❑Splinted* ❑Cement-on implant❑Individual units ❑Screw-retained implant
Reinforcement: ❑None ❑Wire* ❑Fiber ❑Metal
Amount of prep reduction: ❑1 mm* ❑2 mm
❑Perio treatment: Prepare tooth below gingival
on tooth #(s) ____________ by __________mm
❑Pontic site healing: Prepare ovate socket
on tooth #(s) ____________ by __________mm *Standard unless specified otherwise
Indicate Shade Here
Signature _________________________________________________________ License # _____________________________(see reverse for limited warranty details)
❑ Check here to manufacture ceramics or full-cast using CAd/CAM
❑❑❑* ❑
NIGHTGUARDS/BITE SPLINTS ❑ Upper ❑ Lower
❑ Comfort H/S (hard/soft)* ❑ Comfort (hard) ❑ Semi-Hard EVA ❑ Soft EVA ❑ Astron CLEARsplint ❑ Processed Acrylic
ALL-CERAMIC RESTORATIONS ❑IPS e.max CAD* (Posterior) ❑IPS e.max veneer
❑IPS e.max Press* (Anterior)
❑Vivaneers No-Prep Veneers* ❑IPS Empress
Indicate stump or present tooth shade for all-ceramics
PRESENT TOOTH OR STUMP SHADE
Indicate Shade Here
Labial Butt 360° Butt Junction Junction ❑ ❑ ❑* ❑
GLIDEWELL LABORATORIES4141 MacArthur Blvd. • Newport Beach, CA 92660
800-854-7256 • Fax 800-599-9564 Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑ Photos ❑ Other: ___________________________
• UNIVERSAL Rx •
See Reverse for Working Times
Dr. Name _________________________________________________ Phone #__________________________
Acct. # ____________________________________ Patient Name ____________________________________
Address/E-mail _____________________________ Deliver by 5 p.m. on ____________________________
First Last
All Restorations Made in the USA
BITE SPLINTS / NIGHTGUARDSq Comfort H/S Bite Splint (Hard/Soft) q Comfort Bite Splint (Hard)
IF OCCLUSAL CLEARANCE IS LIMITED:q Call Doctor q Adjust Opposing q Make Metal Stop/Occlusion q Adjust Prep & Mark in Red q Make a reduction coping
P ____________________
PAD __________________
C ____________________
MS ___________________
ML ___________________
MO ___________________
FC ___________________
REDUCTION COPING____
IMPLANT ______________
CA CLASP _____________
CLASP ________________
R ____________________
S ____________________
POST F C S
PM ___________________
ATTACH M/F ___________
ERA ATTACH __________
ETCH _________________
WE ___________________
DT ___________________
E.max Stain ____________
E.max Layering _________
OVERNIGHT COURIER SERVICE
We honor VISA, MASTERCARD, DISCOVER CARD & AMEX.All cases returned via Overnight Courier Service
TERMS: All accounts are payable within 30 days of statement date. Accounts not paid within the stated terms will be sub-ject to C.O.D. status and a late charge of 2% of the unpaid balance. Prices subject to change without notice.
LIMITED WARRANTY/LIMITATION OF LIABILITY: Glidewell Laboratories (“the lab”) provides dental laboratory services(“devices”) in the belief that such devices will be useful but WITHOUT ANY WARRANTY—without even the implied warrantyof MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE—except that, subject to the return of devices that areplaced and then fail, the lab will, in its sole discretion, either repair or replace such devices without charge for the lab’s costof materials and workmanship or refund the original price paid, for a period of ninety (90) days from the date of delivery (here-after referred to as the lab’s “remake warranty”). The remake warranty does not cover breakage resulting from accident ormisuse. The lab’s remake warranty is the lab’s sole obligation and the client’s sole remedy: you agree to pay all other costs,such as but not limited to the cost of preparation or veneering. Except where prohibited by law, THE LAB WILL NOT BELIABLE FOR ANY LOSS OR DAMAGES ARISING FROM THE USE OF DEVICES, WHETHER DIRECT, INDIRECT, SPECIAL,INCIDENTAL OR CONSEQUENTIAL, regardless of the theory asserted, including warranty, contract, negligence or strict lia-bility. You agree to indemnify and hold the lab harmless from and against any claim or demand, including reasonable attor-neys fees, made by any third party due to or arising our of your use of said devices. The lab does not guarantee the perform-ance of independent carriers. You acknowledge that limitations on liability are a usual part of business-to-business relation-ships, and a common practice in the dental industry, and that such limitations as specifically stated above are relied upon bythe lab when establishing the cost of providing dental laboratory services to your order. All matters arising from said relation-ship shall be interpreted and enforced in accordance with the laws of California.
IN-LAB WORKING TIMES
CopingsPFM/Captek/Lava/Wol-Ceram/Cercon/Prismatik CZ ......................... 3 daysProcera Copings ..................................................................................... 7 daysProcera Custom Implant Abutment ....................................................... 8 days
Unfinished CrownsPFM/Captek/Lava/Wol-Ceram/Cercon/IPS Empress/IPS e.max/CZ .. 4 days
Finished CrownsPFM/Captek/Lava/Wol-Ceram/Cercon/IPS Empress/IPS e.max/CZ .. 5 daysBioTemps Provisionals with wire or fiber reinforcement ..................... 5 days
with cast metal substructure................................................................... 6 daysextra cost for rush service........................................................... 1, 2 or 3 days
Transition Crowns & Bridges ................................................................. 6 days
Please allow for the full working time on each type of product. Working times do not includeWeekends or Holidays. BioTemps Rush Services available (see box below).
All BioTemps rush cases must be pre-scheduledby calling Customer Service before the case is shipped.Time of pick-up and delivery may affect turnaround time.
FOR LAB USE ONLYTELEPHONE CALL RECORD
LAB ACCT#
PATIENT/ID
RE
RESULT
DATE DUE IN LAB
DATE OF CALL INITIAL
To pre-schedule your BioTemps rush case, call: 800-787-4736
Hogan Dental Lab offers the following:
Margins not defined: _____________%
___ Pull marks: M____D____L____B____
___ Tissue over margins: M____D____L____B____
___ Build up: M____D____L____B____
___ Bubble: M____D____L____B____
IMPRESSION
___ Cut the impression to create bite registration.
___ Used the impression to set the bite.
___ Hand articulation based on wear marks.
___ Light & heavy body not intact at prep
PFM (base, noble and high noble alloys)IPS e.max® BRUXZIR®
ZIRCONIAVENEERSIMPLANTSBITE SPLINTS/NIGHTGUARDS
HOGAN DENTAL LABORATORYTERMS AND POLICIES
WARRANTY: Hogan Dental Laboratory (HDL) guarantees its work for one year against defects in materials and craftsmanship. Please note: Bite Splits/Nightguards carry a 6 month warranty.REMAKES: All remakes will be at no charge except under the following circumstances: Dentist did not resubmit all original goods including impressions, models and restorations. HDL must have these goods to assess possible restoration or repair cost to dentist and to determine if original product is repairable or necessitates remanufacture. HDL inquired about the die, margin or impression. However, the dentist approved and requested the completion of the case. HDL requested for a framework try-in, but the dentist declined and asked for a completed case. The teeth are re-prepared.TERMS: Prices subject to change without notice. All accounts are payable within 30 days of statement date. Accounts not paid within the stated terms will be subject to COD status and a late charge of 2 percent of the unpaid balance. All costs for collection on any account will be the responsibility of the debtor.