Part Upper Part Lower Full Upper Full Lower Permanent Temporary Maurice Hood Dental Laboratory Ltd, Houghton Street, Oldbury, West Midlands, B69 2BB Tel: 0121 544 8855 - email: [email protected] - web: www.mauricehood.co.uk Job Number: (Lab Use Only) Appointment Type: Date Required: Special Tray / Bite Try-in Re-try Fit / Finish Patient Age: Shade: Please give full details and dates of work required now plus any planned extractions or implants to be placed. For temporary dentures what permanent restoration is likely to be required: Female: Male: Notation: 32 38 37 36 35 34 33 31 48 47 41 42 43 44 45 46 28 27 26 25 24 23 21 22 11 12 13 14 15 16 18 17 Dentist: Dentist Email: Patient Name: Practice: Prosthetic & Orthodontic Work Rubber Imp Alginate Imp Study Model(s) Old crown for shade match Bite Registration Photograph(s) emailed Components Face Bow Other: Enclosures: RESTORATION OPTIONS: Type of Prosthesis Ortho Bite Raiser (Hard) Bite Raiser (Soft) Bleaching Tray ORTHODONTIC/MOUTHGUARD: Signed: ENCLOSURE REVIEW (lab use): Upper Lower Upper Lower Upper Lower Upper Lower Mouthguard Colour Upper Lower Chrome Upper Chrome Lower Flexible Dent Special Tray Full Full Upper Lower Upper Lower Skele Plate Skele Plate REPAIR/ADDITION/RELINE: Upper Denture Lower Denture Repair Repair Addition Reline Addition Reline Magnet Retained Telescopic Retained Milled Crowns Immediate extractions planned Space for implant / bone augment Denar mounting