Doctor Signature (Remember to select shade, age, gender, and delivery date)

Fixed

Crown & Bridge/Ceramics

Flat Unit Pricing (metal included)

DWT Pricing (metal not included)PFHN Yellow Gold

PF HN- White (standard)

Partial ridge No ridge High water Bullet

Pontic Design Metal or Porcelain (choose one)

Metal Free Restoration

PF Noble-WhitePFNP

Phoenix Plus (collarless, 90% yellow gold)

Full Cast HN-Yellow (standard) Full Cast Noble-Yellow

Nautilus Full-Contoure.max ®

e.max® Esthetic

Ceramage Composite

Occlusion In occlusion Foil opposing Out of occlusion

I would like a phone call regarding instructions Comments:

Nautilus Core

Dental Prosthetic Services

Doctor:Address:City:State: Zip:

Phone: ( )Special delivery instructions:

Patient:Age: Youthful Middle-Age MatureGender: Male FemaleShade: Tooth #:

Delivery by 5:00pm on:

Simple Z

Porcelain butt margin (requires 1mm shoulder prep)

Shade Details

e.max or Core prep shade

E-mail photos to shades@dpsdental.comPhotos e-mailed:

Characterization photoClearmatch photo

Tooth and Shade Characterization

Please send my office: Rx (Fixed) Rx (Removable) Rx (Sleep/Ortho) Boxes Mailing Labels 1150 Old Marion Road, NE Cedar Rapids, Iowa 52402

319-393-1990 / 800-332-3341 Fax 319-393-8455

E-Mail dps@dpsdental.com

Design Choice s (choose one)

Metal or Nautilus Core