843 Quince Orchard Blvd. Ste C&D Gaithersburg MD, 20878 Ph: 240.912.9670 [email protected] www.lintecdental.com Doctor’s Name: Address Phone # Acct # Email Address Paent’s Name: Age Female Male Deliver by 5 p.m. on Review Time: Enclosed with case: Impressions Models Bite Photos Other: Denture Removable Paral Dentures Splints/Nightguards Repair Ivoclar DCL Denture CAD/CAM Denture Immediate Denture Doctor’s Name: Signature License #: Custom Tray Occlusion Rim Wax setup try-in Finish SLA metal frame Valplast Flipper Ultaire AKP Frame try-in Frame w/occlus. Rim Frame w/setup try-in Finish Hard Soſt Hard & Soſt Reline Breaks/Cracks Add Clasp Add Tooth Add Retenon Minor Connector Maxillary Mandibular Clasp Opons Tooth # Rest Areas Tooth # Lab Select Lab Select Lab Select Metal Lab Select Lab Select EstheClasp Thermoflex Removable Addional Notes SHADE