Denture Prescription Form


   Time:

Denture

Custom Tray                  Bite Block

           Set-Up                             Processed Base

Finish

Conventional Packing                  Success Injection 199

Baseline Denture
* Includes New Tek Teeth

Complete Denture                        Acrylic Partial

                                Baseline Framework                     Set-Up & Finish Baseline Partial

Partials

     Survey and Design                       Metal Framework

          All Acrylic                                       Immediate                 

             Nesbit                                             Flexible Injected Resin

                        Flexible Clear Clasps                    Flexible Tooth Colored Clasp

Orthodontic

Nite Guard                                      Gelb Appliance

  Retainer                                           TPA or LHA        

Space Maintainer                                                           

Repairs

Reline           Denture Repair           Laser Weld

Teeth

New Tek                       Ivoclar PE

                  Portrait IPN                  Other  


Instructions:

Please Send:

                   RX Forms           Boxes           Other 


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