Age: Patient: Address: Case Due Date: Airbills Mailing Labels Boxes Smile Design Rx RX-Prescriptions Please Send Please Call the Dentist Brux Crown: Lava: 1 to 6 units anywhere in the mouth All-Ceramic Restorations (Please indicate stump shade) Captek 24k gold Cerec: Digital Impression, e.Max, Empress, Zirconia, Brux Crown (CAD/CAM) Procera: Crowns anywhere in the mouth Chromatech: Feldspathic veneers. Porcelain to Metal Base Alloy White Noble White High Noble Yellow High Noble Full Cast Crowns Base Alloy White Base Alloy Yellow White Noble Fixed Gold High Noble VALPLAST ULTRAflex CLEARsplint Niteguard Ortho Appliance Frame Try-in Setup Try-in Fully Fabricate Process / Finish Temporary Patient Information: Margins Porcelain Shoulder Metal Porcelain to Metal With Lingual Band Occlusion Metal Occlusion IN Occlusion OUT of Occlusion Surface Texture Smooth Moderate Heavy Doctor's Technical Preference Porcelain Occl. Implants Contacts Metal Preferences High Yellow Noble High White Noble White Noble Base Alloy Heavy Medium Light Custom Abutment Gold Noble Removable Surgical Guide Scan Guide Other Temporaries Other Reduce Opposing Cutting Coping Terms: Accounts are due and payable upon receipt. A 2.5% monthly service charge will be added to all account balances after the 20th of each month. Balances that become 60 days past due will go on an automatic COD basis collecting the total balance due. Delinquent accounts will also be responsible for any/all legal costs and collection charges. Your signature indicates personal guarantee of these terms. All fees are due and payable in Bexar County, San Antonio, Texas Check this box for my digital signature Doctor's Instructions for Case: Excellent Fair Poor Patient: Shade: Stump Shade: Quality Control on Previous Case Removable Appliances Signature Lava Cerec Hybrid Empress: Crowns, veneers or inlays. e.Max: Crowns anywhere in the mouth. W/o Lingual Band Male Female After hours number Todays Date: Doctor: Address: City: ST: Zip Code: Phone # 1950 Bandera Road San Antonio, TX 78228 1.800.683.1025 Local #: 210.735.1433 FAX #: 210.735.2127 www.authenticlab.com Texas Reg# 01470 Dr. Lic# email: Upgrade to Microtech Restoration Lifetime Warranty Copyright PACT Consulting, LLC (CAD/CAM) Cement or bond (CAD/CAM) Cement or bond Indicate layered or stained. Must be bonded Must be bonded 3-unit anterior bridges Cement or bond DESIGN UPPER DESIGN LOWER