DenMat Lab Rx Form
2Pages

PATIENT □ MALE □ FEMALE AGE Select the desired veneer type: □ Feldspathic - Cerinate® □ Lithium Disilicate □ Lithium Disilicate with Cutback ACCOUNT NUMBER Crown & Bridge Select the desired crown type: □ Lithium Disilicate □ Lithium Disilicate with Cutback □ Cerinate Full Contour (Anterior Only) □ LumiZir Zirconia Natural (High Translucency) □ Lumizir Zirconia Full Contour □ Lumizir Zirconia w/Stacked Porcelain Select the desired bridge type: □ Lithium Disilicate Bridge (Anterior Only, Single Pontic 3 units) □ Lumizir Zirconia Full Contour Bridge □ Lumizir Zirconia Full Contour Bridge w/ Stacked Porcelain □ Framework Try-In DR.’S LICENSE NUMBER SIGNATURE Service Type □ Standard Service $239 — Pricing varies with material selection. Would you like photo approvals? (Additional charge will apply.) □ No Yes (please select) □ Wax □ Bisque □ Final □ All Please note that if you choose to approve photos at each stage, your approval will be required before production moves to the next phase. □ Signature Service $279 — Includes advanced color matching, artistry, state-of-the-art processes and photo documentation of the design, bisque phase, and final restorations before shipping. r. — Additive Reductive Template Process Select Desired A.R.T. Preparation Approach □ Additive Only The patient does not want any tooth reduction. See reverse for more □ Strategic — Additive and Reductive detailed descriptions Strategic reduction while maintaining arch form. of A.R.T. preparations. □ Idealized — Additive and Reductive Moderate to significant tooth reduction to optimize esthetics. A.R.T. Consultation — Check here if you would like to receive a phone call from the DenMat Lab Consulting Team Depending on your Desired Preparation Approach, your A.R.T. case will come with the following: Case Submission Checklist for A.R.T. Cases. Please ensure that you submit all required materials. □ Pre-Op VPS Impressions □ Full Bite Registration (no wax) □ Full Face Natural Smile Photos □ Kois earless face bow bite plate (eyes open) (for 6 units or more) □ Full Face Lateral Photo Select Pontic Design: □^-^ Ovate n^^Full □ Follow shade tab □ Add gingival warmth □ I need shade masking (Please call me) Gingival third shade □ LumiGuard (soft nightguard) — Check here if you would like to add a LumiGuard to this case Case Design Specifications □ Desired length of the centrals (mm) □ Placement wrap □ Incisal wrap □ Alignment □ Additional length: O .5 mm O 1 mm O 1.5 mm □ Complete diastema closure □ Partial diastema closure (please specify)_ Teeth & Style Select the teeth to be restored: □ Natural Existing shape and form maintained, restoration that mimics nature. □ Hollywood Changes the original form and shape.Generally follows Golden Proportions. This may require more tooth reduction. Prep and Opposing Adjustments If Inadequate Clearance: □ Spot opposing □ Call me if reduction exceeds 1 mm Conservative Prep Adjustments: □ Spot prep □ Provide a reduction guide Incisal Edge Specifications: Central Incisors □ Square □ Round Lateral Incisors □ Square □ Round Cuspids □ Square □ Flat Bicuspids □ Square □ Flat Incisal third shade Delivery Options Surface Texture □ Light □ Moderate □ Heavy Final Glaze □ Light □ Moderate □ Heavy Occlusal Stain □ None □ Light □ Medium □ Dark Incisal Translucency □ None □ Minimal □ Moderate Standard □ A.R.T. - 7 days □ Lumineers - 10 days □ LumiZir - 10 days □ Combination Cases -10 days □ Signature Service -10-15 days Rush Lumineers □ 4 days □ 5 days □ 6 days □ 7 days Rush A.R.T. Additive Only □ 2 days 3 days Rush A.R.T. Strategic or Idealized 3 days □ 4 days □ 5 days See reverse for delivery option pricing. Quick Check Please indicate items you are sending to the DenMat Lab □ Articulator type □ Bite registration □ Diagnostic wax-up □ Impressions: O Upper O Lower □ Shade tab □ Photos □ Digital impression being sent □ Models: O Pre-op O Opposing □ Stick bite / Face bow □ Returning A.R.T. (see A.R.T. guide)

Abbreviated Terms and Conditions Please see our complete Terms and Conditions available at www.denmat.com/termsofuse Choose this option if the patient and doctor are unwilling to accept ANY reduction or modification at all. Although the DenMat design team will produce the best possible design, esthetics may be comprised in favor of existing tooth structure retention. For the best possible custom-made product, please make sure you are ordering the correct size, quantity, shade, and material application. If we make an error or if your order was inaccurate, we will make every attempt to remedy...