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

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Part Upper Part Lower Full Upper Full Lower Permanent Temporary Maurice Hood Dental Laboratory Ltd, Houghton Street, Oldbury, West Midlands, B69 2BB Tel: 0121 544 8855 - email: [email protected] - 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 any planned extractions or implants to be placed. For temporary dentures what permanent restoration is likely to be required: Female: Male: Notation: 32 38 37 36 35 34 33 31 48 47 41 42 43 44 45 46 28 27 26 25 24 23 21 22 11 12 13 14 15 16 18 17 Dentist: Dentist Email: Patient Name: Practice: Prosthetic & Orthodontic Work Rubber Imp Alginate Imp Study Model(s) Old crown for shade match Bite Registration Photograph(s) emailed Components Face Bow Other: Enclosures: RESTORATION OPTIONS: Type of Prosthesis Ortho Bite Raiser (Hard) Bite Raiser (Soft) Bleaching Tray ORTHODONTIC/MOUTHGUARD: Signed: ENCLOSURE REVIEW (lab use): Upper Lower Upper Lower Upper Lower Upper Lower Mouthguard Colour Upper Lower Chrome Upper Chrome Lower Flexible Dent Special Tray Full Full Upper Lower Upper Lower Skele Plate Skele Plate REPAIR/ADDITION/RELINE: Upper Denture Lower Denture Repair Repair Addition Reline Addition Reline Magnet Retained Telescopic Retained Milled Crowns Immediate extractions planned Space for implant / bone augment Denar mounting

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Page 1: Prosthetic & Orthodontic Work fileSkele Plate Skele Plate REPAIR/ADDITION/RELINE: Upper Denture Lower Denture Repair Repair Addition Reline Addition Reline Magnet Retained Telescopic

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: [email protected] - 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

mailto:[email protected]

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