Reserved Appointments Phase 1 Pre-Diagnostic (bite shell & abutment guide) Doctor: ________________________ Surgery Date: _________ Time _________ Address: __________________________________________________________ Phase 2 Try-In OPTIONAL (Bar w/ teeth set in wax) NOT NEEDED Doctor: ________________________Try-In Date: ___________ Time _________ Address: __________________________________________________________ Phase 2 Provisional Delivery Doctor: ________________________ Delivery Date: ________ Time: _________ Address: __________________________________________________________ Next Day Hybrid Rx O: 561.272.6662 | E: [email protected] Dental Laboratory 601 North Congress Ave, Ste 111A, Delray Beach, FL 33445 P: 561.272.6662 Phase 1 - Reservation & Work Instructions before Surgery Specialist & Patient Information Surgical Dr. Name: ________________________________ Phone: ___________ Signature: ______________________________ License #: __________________ The person signing this work order accepts responsibility for payment and agrees to pay all collection costs including attorney’s fees. A 1 ½ % (18%vr.) finance charge will be added to all balances due over 30 days. I am a surgical specialist operating in a surgical office I am a surgical specialist operating in a restorative office I am a restorative specialist operating in a restorative practice Patient Name: __________________________ Sex: Male Female Chairside Service Phase 1 Pre-Diagnostic Assistance (Anytime) Surgical Appointment Assistance (AM Only) Phase 2 Provisional Delivery Assistance (3:00 PM or Later) No Service Requested Pre-Surgical Phase 1 Items Sent (enclosures) Upper & Lower Study Cast (Required) Kois Dental Facial Analyser Centric Relation Bite (Required) Pictures Screw-Retained Restorative Solution Provisional Options (24 Hours) Final Options (48 Hour) TBS Hybrid Provisional TBS Final Hybrid Printed Hybrid Provisional BioLogic Final Hybrid Printed Crown & Bridge Provisional (crown contours with no pink tissue) Special Instructions Page 1