. 800.259.3717 www.dentalservices.net In an effort to consistently produce to your individual preferences, please complete and return to us with your first case or via fax or email to [email protected]. This profile will be entered into our computer system and be available each time you send us a case. In the event that you need to deviate from this profile, simply indicate it on your prescription. Please feel free to use the space on the back of this form for any additional information to communicate to us. We look forward to working with you! PLEASE CHECK SPECIALTY OFFICE DELIVERY HOURS GP Prostho Ortho Oral Surgery Perio M T W R F How do you prefer we reach you for technical questions & follow up? Office phone Drs Cell Phone Drs Email DENTIST PROFILE FORM Dentist Name License Number Street Address Office Contact (Name + Title) Practice Name Office Phone City Email Address Group Name Dr Cell Phone State, Zip Dr Email FIXED PROSTHODONTICS MARGINS AND COLLARS Lingual Metal Collar Full Metal Collar Metal Occusal, Exclude Buccal Cusp Metal Occlusal, Include Buccal Cusp Full Porcelain Coverage Full Coverage Lingual 2/3 Coverage Lingual Full Metal Lingual 3/4 Metal Lingual 1/4 Metal Lingual PONTIC DESIGN Sanitary Full Ridge Modified Bullet Ovate DIES TRIMMED BY DIE SPACER POST & CORE OCCLUSION INSUFFICIENT CLEARANCE CONTACT AREA SURFACE TEXTURE Doctor Lab None Light Medium Heavy Post & Core as one unit Post seperate Ideal Slightly out Tight Metal Occlusion Reduction Coping Spot/Adjust Opposing Call For Instructions Broad Normal Point Smooth Medium Heavy CONTOUR STAINING Match Patients Dentition YES NO Make Ideal YES NO None Normal deviation in color of anteriors Pit and fissure Exact duplication of shade tab Characterization stain on anteriors BASE PLATE LINGUAL RELIEF POST DAM PALATAL RELIEF SET UP FINISH BORDER EXTENSION TOOTH PREFERENCE Processed Light Cured Vaccum Formed Light Normal Heavy Moustache Butterfly Bead Other Yes No Ideal Characterized Per Study Model Stipple Smooth Rugae Relieve undercuts Full As marked Laboratory Discretion Dentsply: Portrait IPN Bioform Classic Other: & Festoon TRY IN RELIEF FOR LOWER LINGUAL BARS DESIGN PREFERRED UPPER DESIGN CLASP MOST DESIRED CLASP RETENTION TOOTH PREFERENCE Metal Bit on frame Wax set up Finish Heavy Light Moderate AP Bar / Circular / Double Bar Horseshoe Palatal Strap Full Palate All Metal with Backings & Veneers Full Mesh Strengthener Full Metal Coverage Acrylic Post Dam Area Smooth Palate Follow Rx Lingual Bar Full Lingual Plate/Apron Lingual Bar and Kennedy STrap Lingual Bar and Indirect Retainer All Metal with Backings & Veneers Strengthener Bar DE Hinge Follow Rx Follow Rx exactly Modify design as required Reduce opposing as required Modify clasp type, not tooth Call for all design modifications PREFERRED LOWER DESIGN FRAME CONNECTOR SIZE FINISH MOST DESIRED Danity Standard Heavy Lucitone 199 Acrylic Flexible Acrylic Saddle Lock “Hidden Clasp” Roach/T-Bar Modified Roach Esthetic Clasp Flexible, Clear Flexible, Tooth Shade I Bar Back Action/Ring Akers/Circumferential Regular Heavy Portrait IPN Bioform Classic REMOVABLE FULL DENTURE REMOVABLE PARTIAL DENTURE NOTES