Crown & Bridge Prescription Form


   Time:

Porcelain

PFM                                        PFM with Porc. Butt Margin

                     PFM with Metal Collar        Porcelain Facing With Metal Occlusion

Captek Crown                      Maryland Bridge                  

Metal

Full Gold                                Gold Post                              

     Full Alloy                                Metal Framework (one piece)

                             Gold Inlay                              Metal Framework (for solder or laser weld)

Gold Onlay                            Laser Weld                             

Metal Types

High Noble           Semi Precious           NP

E-MAX Pressable

E-MAX Inlay                                      E-MAX Onlay

  E-MAX Laminate                              E-MAX Crown

Implant

Titanium Abutment           Zirconia Abutment           Screw Retained Abut (your choice of material)

Occlusion Staining

None           Light           Moderate           Heavy

Other

Diagnostic Wax-up           Processed Temps           Study Models/Neat Bases


Instructions:

Please Send:

                   RX Forms           Boxes           Other 


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