FIXED RESTORATIONSPFM (Porcelain to Metal)Design□ Metal Lingual Coverage*□ Metal Lingual Band□ Metal Occlusal* □ No Metal Showing

□ Porcelain Butt Margin* □ Fit to Existing Partial*

□ Design for Future Partial*

□ PFM NP□ PFM NP (Nickel Free)□ PFM Noble□ PFM High Nobel _40% _75%□ Captek

Full Metal Crowns (FCC)□ FCC NP □ FCC Noble □Yellow □White

□Yellow □White□ FCC High Noble

All Porcelain/Zirconia□ e.max® Crown □ e.max® Veneer □ e.max® Inlay/onlay □ IPS Empress Esthetic

□ Z-Special Solid (full contour zirconia)□ Z-Special Hybrid

(layered facial/buccal)

□ Z-Special Esthetic (layerd zirconia)

Miscellaneous

□ CAD/CAM Temporary Crowns□ Conventional Temporary Crowns□ Diagnostic Wax Up

Dr/Practice: Address: Phone:

Patient Name: □ Please call before proceeding with case RX Date:

Due Date: (10 day turnaround from date we receive case.) □ Redo□ Previous Case #

COMMENTS

Implants & Attachments:Implants Manufacturer:

Brand/Name: Diameter:

□

Zirconia

□

Ti/Zirconia

□

Titanium

□

Stock

Parts Included Y/N? □ Yes □ No

Teeth Shade: Tissue Shade:Gingival Body Incisal Stump Shade

□ Clear□ Pink□ Maharry □ Dark Maharry

Pontic Design

1

32

31

30

2928

2726 25 24 23

2221

2019

18

17

2

3

45

67 8 9 10

1112

1314

15

16

UPPER

LOWER

□

□

□

□

□

Dr. Signature: (client agrees to all terms & conditions specifi ed on reverse of form)

License #:

*additional fee applies.

Specialty Dental Studio, LLC10040 Ravello BlvdFort Myers, FL 33905Phone: 877-787-6274

www.specialtydentalstudio.cominfo@specialtydentalstudio.com

□ Stay Plate (2-5 teeth) □ □ □

□ Acrylic Partial (6+ teeth) □ □ □

REMOVEABLE RESTORATIONSDesign□ Upper □ Lower □ Standard □ Immediate □ Unilateral □ Permium Teeth* □ Premium Acrylic*(Lucitone 199) SPECiALFLEX (Flexible Partial)

Frame BBlock TryIn Finish

□ SPECiALFLEX Basic □ □ □ □□ SPECiALFLEX Single tooth/Flipper □ □ □ □□ SPECiALFLEXHybrid w/Cr-Co Frame □ □ □□ SPECiALFLEX Hybrid w/Vitallium 2000+ □ □ □Conventional Dentures and Removable Partial Dentures(RPD)□ Conventional RPD w/Cr-Co Frame □ □ □ □ □ Conventional RPD w/Viatllium 2000+ □ □ □ □

Miscellaneous□ Custom Tray □ Reline □ Repair□ Add Teeth □ Name on Denture □ Add Clasp

□ Complete Denture □ □ □

□ Flipper (single tooth) □ □ □

e.max® is a registered trademark of Ivoclar Vivadent, Inc.

TERMS, WARRANTIES AND CONDITIONS

CLIENT AGREEMENT

By submitting this Rx form to Specialty Dental Studio LLC, you agree to abide by all terms and conditions listed on this form. Specialty Dental Studio LLC is not liable for incidental or consequential damages of any nature, including inconveniences, lost wages, chair-time, or pain and suffering.

TERMS

Specialty Dental Studio LLC will issue an invoice with every case. At the end of each month you will be issued and mailed a statement disclosing the total amount owed. Payment of the complete amount disclosed in the statement has to be submitted to Specialty Dental Studio LLC no later than 30 from statement issuance (Net 30).

Specialty Dental Studio reserves the right to charge a late fee of 2% per month (annual 24%). Orders on passed due accounts will be shipped COD (Cash on Delivery) for the amount of the invoice and any passed due amounts. In case of returned checks there will be a $50 charge.

All disputes shell be governed by Florida law, with the prevailing party to recover all fees and expenses.

WARRENTIES

Specialty Dental Studio warranties that all dental devices are made in accordance with your specifications. If a device is returned, Specialty dental studio will replace or repair the device at no charge in accordance with the fallowing conditions:

A. Porcelain fused to metal or Zirconia restorations come with 5 year limited warranty. B. Full porcelain crowns,veners,inlay etc. restorations come with 1 year limited warranty. C. Removable Prosthetics come with a 1 year limited warranty if failure is due to material or workmanship. D. For other products not listed the warranty is 90 days from date of delivery by us.

REMAKES

If Specialty Dental Studio accepts your order, our work is guaranteed according to the terms outlined above. If we as for new model or new impression and you ask us to proceed anyway, any remakes will be done at full charge.

In order for the remake policy to be honored as stated above, all dental devices, original models and impressions have to be returned to us together with the new impression or model. We will assess a charge of 50% of the total value of the remade case if these items are not returned. If you choose to use the original device as a temporary and intend to return it to us when the replacement is delivered please let us know on the “comments” area of the Rx form.

DISCLOSURE

In accordance with Florida law, we hereby disclose that products may be manufactured in the U.S., Mexico or China. All materials used in the fabrication of dental devices are approved by the ADA and FDA with the countries of origin being the United States and Europe.

Manufacturer Material Product type Country American Dent-All Superbond Non-Precious USA

Dentaurum Remanium 2001 Non-Precious (Nickel

Free)Germany

Argen Argelite 61 Semi-Precious USAArgen NobleCrown NF Semi Precious USA

Argen Argedent Euro Porcelain to Precious USA

Argen Argedent 75 Porcelain to Gold USAArgen Argedent BIO 862PF Porcelain to Gold USA

Argen Argenco 75 Full Gold Crown -- Au

74.5%USA

Argen Argenco 58 Full Gold Crown -- Au

58%USA

Argen Argenco 40 Full Gold Crown -- Au

40%USA

Argen Argenco Y+ Full Gold Crown -- Au 2%

USA

Argen Argenco W+ Full Gold Crown -- Au 2%

USAPrecious Chemicals

LtdCaptek Nano Universal Captek Crown USA

Ivoclar Vivadent IPS Empress Esthetic Crown, Veneer,

Inlay, OnlayLiechtenstein

Ivoclar Vivadent IPS e.max Press Crown, Veneer,

Inlay, OnlayLiechtenstein

UPCERA PLS-Bruxers-ST Zirconia ChinaUPCERA PLS-Bridges - HT Zirconia China

Zirkonzahn Zirkon TranslucentToronto Bridge

Zirconia BarItaly

UPCERA PLS Abutment-ST Zirconia Abutment China

Ivoclar Vivadent IPS InLine (Default) For Porcelain Fused to Metal

Liechtenstein

Ivoclar Vivadent IPS e-max Ceram Procera/PLS Zirconia Liechtenstein

Noritake CZR Default porcelain for

ZirconiaJapan

Bredent VKS Locks Germany

Sterngold ERA Locks USA

Thermoplastic TCS Unbreakable Drk. Flexible Acrylic USAComfort System TCS Unbreakable Flexible Acrylic USA

Valplast Valplast Flexible Acrylic USA

Dentsply Austenal Thermo Flex Flexible Acrylic USA

Dentsply(Tian Jin) QC-20 (Heat Cured) Conventional Acrylic China

Dentsply Lucitone 199 High Impact Acrylic USA

Dentsply(Tian Jin) Cosmo HXL Teeth Resin Teeth China

Dentsply(Tian Jin) QC-20 Thermoguard (Hard) China

Keystone Industries Soft EVA (3.0 mm) Thermoguard (Soft) USA

Yamahachi Dtl. Mfg. CAD - PMMA Disc Temporary Crown Japan

Yamahachi Dtl. Mfg.Re-fine Bright/Quick Selfcuring Acr. Res.

Temporary Crown Japan

Dentaurum Remanium GM 800+ CoCr Germany

Dentsply Austenal Vitallium 2000 Alloy Vitallium 2000 USA

Bredent VKS-OC, VKS SG / VARIO SOFT 3

Locks USA