PATIENT NAME FINISHED PERMA FINISH STUDY MODELS 3D IMAGING TRIM ONLY MAKE 2 SETS DUPLICATION FROM DR’S CAST AGE: D.O.B. DR. NAME/ OFFICE LAST NAME 1 2 3 4 5 0 OTHER 6 7 8 9 Years. Months GENDER FIRST NAME Perma inked lettering Typed labeling Pour impressions twice M.I. CASE NUMBER ADDRESS CITY STATE ZIP OFFICE PHONE E-MAIL CASES RECEIVED DATE RECEIVED RUSH / SR / HLD OFFICE USE ONLY DIGITAL BASIC DIGITAL STANDARD DIGITAL PLUS Image only Image + Trim study model image + Finished study model WE NEED: POSTAGE FREE LABELS SHIPPING CARTONS PRESCRIPTION SHEETS OTHER DATE SENT: DUE DATE: RUSH CASE DUE DATE DISINFECTED BY: (INITIALS) CRYSTAL STUDY MODEL LAB PERFORMANCE. QUALITY. SERVICE. 14241 Imperial Hwy. Suite A, La Mirada, CA 90638 Tel: 562-941-1675 Fax: 562-941-4115 Email: [email protected] STL FILE CAST IMPRESSION (additional $10.00) LAB USE ONLY NOTES: U L B WB HLD USE ONLY(1 Set ) Location # BIC # Office NPI # All cases will be processed as regular patient if HLD USE ONLY is not checked