doctor’s name dental quest address laboratory, inc city state
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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 [email protected] • www.dentalquestlabs.com
Try In Finish Reset
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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: _____________