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 [email protected] 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 [email protected]
Design Choice s (choose one)
Metal or Nautilus Core
