Dr. Signature:________________________ DDS License# ______________ Signature is acceptant of sole responsibility for payment and agrees to pay all legal costs in the event of a suit, including reasonable attorney fees. San Diego Dental Design. requires that each case be accompanied by a lab slip - this is considered a binding work order and is subject to all stated terms and conditions. Patient Name: ____________________________________________ Age: _______ Preparation Date: ____ /____ / ____ Delivery Date: ____ / ____ / ________________ Dr. Name: _____________________________ Dr. Phone: ______________________ Address: _______________________ City: _________________ Zip Code: ________ Pontic Design Crown Design All PFM NP Tilite Alloy SP Semi-precios HN White HN Yellow Captek Call for a pickup: (760) 855-7091 12285 World Trade Dr. Ste G San Diego CA, 92128 San Diego Dental Design All Zirconia BruxZir Lava HT Zirconia Layered Zirconia Inlay / Onlay Inlay / Onlay Implant Crown Ceramic PFM Captek Zirconia Screw Retain Pink Gingival Porcelain Zirconia Abutment Titanium Abutment Hybrid Abutment Hader Bar Abutment & Bar Placemat Jig Follow Tissue Contour RX Number Products CDT Concorde Dental Technician L a b Solid Crown Layered Crown Framework Try-in Shade# Porcelain Margin Buccal Margin Metal Margin 360 Margin Light Medium Heavy Contact Light Medium Heavy Occl Contact Please make sure that the due date is 1-2 days before Pt’s appointment dete. Cement Retain Surgical Guide X P All Ceramic e.max Crown e.max Veneer e.max layered Ceramic Post please print legibly so we can understand your case better. X P Dental Design Implant Technology Zimmer • Straumann • Astra Tech • Bio Horizons • Mega’Gen • Biomet 3i • Nobel Biocare