RX FORM

Doctor's Name:

Patient's Name:

Street:

City, State, Zip:

Phone:

Age:

Sex:

Due Date:

Lab Use Only:

Case Design Pref

Final Shade:

Stump Shade:

#8-‐#25__mm

#9-‐#24__mm

Smile Catalog Selection:

Opposing to be restored?

Golden Proportions?

Full Gold Crown:

restorative opt check

Lingual Collar __mm:

Full Band __mm:

Checkboxes

Implant Brand:

Implant Size:

Checkboxes

Tooth numbers to be restored:

dg planning check

Street: All Phone:

Case Notes:

Dr's Signature:

Clear Signature

Date: