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Prescription Forms

We always try to keep you fully stocked with Rx Forms for your cases but if you are running low:
 
 

Fill out our Online RX Form Here:

 



Male Female







Type Of Restoration

For all anterior cases please provide the following items and mark they have been sent


ALL PORCELAIN
VENEERS





PORCELAIN TO METAL



GOLD




FULL CROWN/BRIDGE








ALLOYS-CERAMIC






ALLOYS FOR GOLD WORK





INLAY/ONLAY




DR. REQUEST






METAL DESIGN





GOAL OF FINAL CASE












IF INSUFFICIENT ROOM



PONTIC DESIGN







RIDGE RELIEF











None Light Medium Dark


None Minimal (0.5) Moderate(1.0) Maximum(1.5)


Clear (Blue) Smoke (Grey) Frosted (Chalky White) Amber (Orange)


Heavy Medium Light Smooth (No surface texture)



SPECIFIC INSTRUCTIONS:





Please Send:






Terms: Net 30 days. A 2% a month finance charge is added to all past due accounts. Accounts over 30 days past due will be placed on COD including outstanding balance due with shipment of case. Dentist will be responsible for all collection costs, including attorney’s fee to collect past due balance. By signing below you are legally obligated to these terms.