Crown & Bridge Rx MARGIN DESIGN

Laboratory Procedure Prescription Please circle your choice(s) of margin combination

REQUIRED INFORMATION *

Doctor Name _______________________________________________________

Last First

Practice Name_______________________________________________________
Show no All porcelain Metal collar Facial Lingual Metal Metal
metal 360°* shoulder 360° 360° porcelain metal collar occlusal lingual
Show No Metal
Show Show
No 360
NooShow
Metal Metal
360o All
Show
No
360
Porcelain
Metal
Show
o No
All Show
Metal
360
All
NoShoulder
Porcelain
Metal
No
Porcelain360
Metal
All
o360
Porcelain
360
o360
ShoulderShoulder
Allo360 Metal
o Porcelain
All
o Porcelain
Shoulder
All
360 Collar
Porcelain
Metal Metal
o Shoulder
360 360
Shoulder
Collar Collar
o360Metal
oShoulder
360 o360 360
Metal
Collar
o Facial
o360 Metal
FacialCollar
360
Metal
Collar
o 360
oo Porcelain
Facial Collar
Porcelaino360o360
Shoulder
Porcelain
Facial Facial
Porcelain
180
oShoulder
ShoulderFacial
Porcelain
Facial
o180 Porcelain
Shoulder
180
Porcelain
o Shoulder
180
Shoulder
oShoulder
180 o180 o180 Metal Occlusal
Metal Metal Occlusal
Occlusal Metal
mm. Metal
Occlusal
Metal
Metal
Occlusal
Metal
Lingual
Occlusal
Metal Metal
Occlusal
LingualLingual
Metal Me
Lin
Address_____________________________________________________________
o Lingual Metal
Lingual Lingual
Collar
Metal Metal
_____
Lingual
Collar Collar
mm.
_____Lingual
Metal
o _____
mm. Lingual
Collar
Metal
Lingual
mm.Metal
_____
Collar
Metal
Collar
mm.
_____
Collar
_____
mm.
_____
mm.
shoulder 180° (traditional)
o

Phone_______________________________________________________________ CROWN DESIGN

Patient Name________________________________________________________ Characterizations Pontic Design

Patient Chart #______________ □ M □ F DOB______________________ *

Rx Date___________________ Due Date/Delivery on___________________

(standard working time if no date given)

Modified
ridge-lap

Saddle
ridge-lap

Sanitary/
hygienic

Conical

Ovate
Case turnaround times are based on the date the Rx is received at DDS Lab. Please allow
10 business days (M-F) from that date and 13 business days for complex cases.

CASE INSTRUCTIONS
Please CIRCLE single units and BRACKET splinted units Tooth Shade____________________ Shade Guide Used________________
(REQUIRED) (vita is default)
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
Stump Shade___________________ Pink Tissue Shade________________
(REQUIRED FOR E.MAX)
PFM Zirconia / All Ceramic

□ White HN* □ Zirconia Solid If Insufficient Room Occlusal Contact Interproximal Contact
□ Semi-precious (not recommended □ Trim opposing* □ Light* □ Light*
□ Non-precious for anterior) □ Call to discuss □ Open □ Medium
□ Yellow HN (for PFM) □ Zirconia Layered □ Metal occlusal □ Tight □ Heavy
□ High Translucent □ Reduction coping
(max 3 unit bridge) □ Metal □ Resin
□ Solid lingual with □ Metal island
Full Cast
□ no
Trim prep
□ Full cast Yellow HN gold porcelain facial
coping
□ Full cast Yellow noble (2% AU) □ IPS e.max® Press
(max 3 unit bridge) RX SPECIFIC INSTRUCTIONS
□ Full cast White HN □ Lithium Disilicate
□ Full cast Semi-precious Please provide any photos, study models, diagnostic casts with case
□ Full cast Non precious Other Email photos to: ddslabpix@ddslab.com
□ Full cast Medicaid (D2790) □ Diagnostic wax-up **The person signing this form is an authorized signer and, along with the dental practice, accepts

□ Composite resin crown

responsibility for payment of all related charges, as well as any legal costs, collection and other fees
incurred by DDS Lab in the event the account is sent to collections or litigation.

□ Temporary _____________________________________________________________________
□ Temporary w/ metal
_____________________________________________________________________

Return for Restoration _____________________________________________________________________

□ Die trim □ Crown □ Post & core _____________________________________________________________________

□ Bisque □ Bridge □ Rest seats
□ Metal try-in □ No-prep veneer (specify)___________________ Dentist signature**__________________________________________________
□ Finish* □ Veneer □ Crown under partial (REQUIRED)

□ Inlay/Onlay (specify)___________________ Dentist license no.__________________________________________________

□ Implant (REQUIRED)

*Standard design if an option is not selected

5440 Beaumont Center Blvd, Suite 400 | Tampa, Florida 33634 | (877) 337-7800 | www.ddslab.com | DL 10334
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