doctor’s name dental quest address laboratory, inc city state

Doctor’s Name ____________________________Address _________________________________City __________________State ___ ZIP________Phone ________________ Fax ______________Email ___________________________________

Patient’s Name _________________________________

Deliver by _____________________________________

Please call at: _______________________________

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SERVICES

PARTIALSFlexible (Valplast-TCS-Flexstar-Quest Flex)

Premium CastPartials/CompleteMetal Frame &Flexible DentureTransitional

TREATMENT PARTIALSFlipper-1 toothStayplate-2 to 5 teethAcrylic Partial 6+ teeth

DENTURESStandardPremium

CUSTOM TEETH*Standard Resin TeethIPN Portrait Teeth

IMMEDIATESExtract AllExtract Tooth #

SPECIAL INSTRUCTIONS9

8 REMOVABLE RESTORATIONSShade ___________________ Shade Guide ___________________

(CIRCLE SHADE #) 59 62 65 66 67 69 77 81

(CIRCLE TISSUE SHADE) Light Pink Pink Ethnic Clear

REMOVABLE EXTRASBite Rims RepairBite Blocks Cusil Reline Custom TrayHard Nightguard Soft Nightguard Weld Fracture Softliner

ATTACHMENTSRhein ERA Hader Bar

CLASP TYPE Cast Wire

MAJOR CONNECTOR Lab Select Lingual Bar Lingual Plate Horseshoe Palatal Bar Full Palate Double Palatal Bar

DESIGN CLASPINGLab Select RPI WroughtRoach AkersHidden Other _____

REINFORCEMENTWire None Mesh BarCast Metal Frame

DENTAL QUEST LABORATORY, INC.495 Kings Highway, Valley Cottage, NY 10989Phone: (845) 268-6035 • Fax: (845) 268-2288 dentalquest@optonline.net • www.dentalquestlabs.com

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PONTIC DESIGN

Modified Ridge(standard)

No Contact Point Contact No Ridge

CONTACTS

Normal Heavy & Broad Point

CERAMIC SHADE INSTRUCTIONSShade Guide _________

Shade ______________

COPING DESIGN (please circle)

FullPorcelainCoverage (no metal to show)

LingualMetalCollar*

FullMetalCollar

Buccal Cusp.(Porcelain,

MetalOcclusal)

Full MetalOcclusal(Veneer)

FullCoverageLingual

2/3CoverageLingual

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TOOTH NUMBER(S)/CASE DESIGN

Upper

Lower

Restoration on tooth #: (Circle for restoration, X for pontics)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

CHECK APPROPRIATE BOXESFull Partial Nesbit Unilateral___upper arch ___lower arch

COPINGSNon-Precious (NI, Cr)Non-Precious (No NI or Be)Titanium “Tilite”White GoldYellow GoldPFM PORCELAIN TO METALNon-Precious (NI, Cr)Non-Precious (No NI or Be)Titanium “Tilite”White GoldYellow GoldFULL CASTNon-PreciousTitaniumWhite GoldYellow Gold

ADDITIONAL SERVICESPorcelain Butt Margin _________Metal Occlusal ______________Occlusal Rest Seat ___________Maryland Bridge _____________Cantilever __________________Splinted ____________________Post & Core ________________

METAL FREEEmpress 2” CrownEmpress 2” VeneerEmpress 2” Inlay/OverlayWol-Ceram AluminaWol-Ceram ZirconiaCercon ZirconiaIPS E.Max

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Dr.’s Signature:_______________________ DDS License #:______________________ Date: _____________