Doctor Signature (Remember to select shade, age, gender, and delivery date) Fixed Crown & Bridge/Ceramics Flat Unit Pricing (metal included) DWT Pricing (metal not included) PFHN Yellow Gold PF HN- White (standard) Partial ridge No ridge High water Bullet Pontic Design Metal or Porcelain (choose one) Metal Free Restoration PF Noble- White PFNP Phoenix Plus (collarless, 90% yellow gold) Full Cast HN-Yellow (standard) Full Cast Noble-Yellow Nautilus Full-Contour e.max ® e.max ® Esthetic Ceramage Composite Occlusion In occlusion Foil opposing Out of occlusion I would like a phone call regarding instructions Comments: Nautilus Core Dental Prosthetic Services Doctor: Address: City: State: Zip: Phone: ( ) Special delivery instructions: Patient: Age: Youthful Middle-Age Mature Gender: Male Female Shade: Tooth #: Delivery by 5:00pm on: Simple Z Porcelain butt margin (requires 1mm shoulder prep) Shade Details e.max or Core prep shade E-mail photos to [email protected] Photos e-mailed: Characterization photo Clearmatch photo Tooth and Shade Characterization Please send my office: Rx (Fixed) Rx (Removable) Rx (Sleep/Ortho) Boxes Mailing Labels 1150 Old Marion Road, NE Cedar Rapids, Iowa 52402 319-393-1990 / 800-332-3341 Fax 319-393-8455 E-Mail [email protected] Design Choices (choose one) Metal or Nautilus Core