18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 38 37 36 35 34 33 32 31 41 42 43 44 45 46 47 48 165, boul. de la Technologie Ganeau (Québec) J8Z 3G4 T : 819.243.5654 / 1.800.207.3895 F : 819.243.9498 www.milident.com Boxes Rx Forms Pre-printed WayBills REMOVABLE & IMPLANT PROSTHETICS Rx MILIDENT Laboratoire dentaire Dental Laboratory Add _______________________________ Tel ___________________________________ ____________________________________________________________________________________ SVP ÉCRIRE EN LETTRES MOULÉES PLEASE PRINT SHADE Dr ________________________________ Pt ___________________________________ PLEASE PRINT SVP ÉCRIRE EN LETTRES MOULÉES Date ______/______/______ J/D M/M A/Y Signature ________________________________________________________ Licence # _________________________________________________________ DESCRIPTION Rx : Payable dans les 30 jours suivant la récepon de votre état de compte. Payable within 30 days of receiving your statement. Sex M F PLEASE SEND Date required ______/______/______ J/D M/M A/Y Hour _____________ Not booked Please call me over closed_____mm over opened____mm Exisng VD_____mm good Y too short_______mm too long________mm Exisng CUD____mm good X X______mm Y______mm Papillameter High lip line______mm Low lip line______mm PHOTO COMMUNICATION Photo included e-mail images to [email protected] IMPLANT PROSTHETICS Implant supported Overdenture Reset CUD / CLD Finish Metal Reinforcement Set up Central dominant Lateral rotaon Diastema Irregular lowers ANTERIOR TEETH ARRANGEMENT POSTERIOR TEETH Monoplane Semi anatomical Fully anatomical Lingualized Class I / Class II / Class III Convenonal / Gerber trays Bite blocks Framework Framework with teeth Regular Acrilyc Flexible Acrilyc PUD / PLD Metal with clasp Metal with aachment Metal occlusion Thermolock Hard SPLINTS Pureflex Pankey Sport guard JAW RELATION CUSTOM TRAY BITE REGISTRATION TRY-IN All-on-4 Radiographic Stent Verificaon Jig Milled bar Dr. will provide components Duplicate model(s) Use same mould & teeth arrangement Anterior Shade_________ Posterior Shade__________ Mould___________