• REMOVABLE APPLIANCE Rx • Dr.

Name__________________________________________________ Phone #__________________________

GLIDEWELL Acct. #_____________________________________ Patient Name_____________________________________

LABORATORIES First Last

4141 MacArthur Blvd. • Newport Beach, CA 92660 See Reverse for Working Times
Address/Email_______________________________ Deliver by 5 p.m. on _____________________________
800-726-3590 • Fax 800-411-9722
glidewelldental.com Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑ Photos ❑ Other:____________________________
FINAL CERAMIC SHADE
Rx
Indicate Shade Here
PRESENT TOOTH OR STUMP SHADE

Indicate Shade Here

OCCLUSAL STAINING
❑ None ❑ Light * ❑ Medium ❑ Dark
PONTIC DESIGN

❑ ❑ ❑* ❑ ❑
MARGIN AND METAL DESIGN

❑ ❑ ❑* ❑
Labial Butt 360° Butt Junction Junction

❑* ❑ ❑ ❑ ❑

Signature____________________________________________________________ License #________________________________________

❑* ❑ ❑ ❑
(see reverse for limited warranty details) *Standard unless specified otherwise
DENTURES/FLEXIBLE PARTIALS VITALLIUM METAL PARTIALS COMBINATION CROWNS & PARTIALS ❑ Fabricate RPD to fit restoration
❑ Flipper ❑ Denture ❑ Valplast ❑ tcs ❑ WELDENZ ❑ Vitallium 2000* ❑ Vitallium 2000 Plus ❑ tcs/Vitallium ❑ Valplast/Vitallium ❑ Future RPD:__ Vitallium __ Valplast __ Attachments ❑ Obsidian Non-Precious
❑ Dupe denture ❑ Custom tray ❑ Occlusion rim ❑ Wax setup try-in ❑ Titanium ❑ Wironium ❑ tcs/Wironium ❑ Lab select complete design ❑ Obsidian Noble ❑ BruxZir Full-Strength (1,150 MPa) ❑ BruxZir Anterior (650 MPa)
❑ Finish ❑ Name on appliance________________________________
(Additional charge) ________________________________ ❑ Frame try-in ❑ Frame w/occlus. rim ❑ Frame w/setup try-in ❑ Finish SNORING/SLEEP APNEA APPLIANCES NIGHTGUARDS/RETAINERS
Tooth Setup: ❑ Ideal ❑ Characterized ❑ Study model (Upper and lower models with protrusive bite required) ❑ Upper ❑ Lower ❑ Scan/Save File
❑ Male ❑ Female Age ________ MAJOR CONNECTOR ❑ Silent Nite sl* ❑ EMA ❑ Comfort H/S (hard/soft)* ❑ Comfort (hard)
Acrylic Shade: ❑ Std G1 Ethnic: ❑ Med G3 ❑ Dark G4 Maxillary Mandibular Clasp Options Tooth # ❑ TAP ❑ TAP 3 ❑ TAP 3 TL ❑ dreamTAP ❑ Semiflexible nightguard  ❑ Soft nightguard
tcs Flexible Partial Shade: ❑ Lt Pink ❑ Std Pink ❑ Lab select ❑ Astron CLEARsplint ❑ Processed acrylic
❑ Lab select ❑ Lab select ___________________
PLAYSAFE MOUTHGUARDS
❑ Lt/Dark Pink ❑ Dark Pink ❑______________
❑ Kenson Teeth (Included at no extra charge) ❑_______________ ❑ Metal ___________________
❑ Jr ❑ Lt ❑ Lt Pro ❑ Clear-Lock Retainers: ❑ quantity of 2
Shade_______________ Mould________________________ Rest Areas Tooth # ❑ EsthetiClasp ___________________ ❑ Med* ❑ Hvy ❑ Hvy Pro ❑ quantity of 4
❑ Premium Brand Teeth (Extra charge applies) ❑ Lab select _________________ ❑ Thermoflex ___________________ ❑ Helmet strap Specify color(s) on Rx ❑ quantity of 6
Shade_________ Brand________________ Mould_________ ❑______________ _________________ ❑ ________________ ___________________ ❑ Name __________________________________________________ ❑ Clear ortho ❑ Hawley ❑ QCM Clear-Wire
©2018 Glidewell Laboratories P/N 1009161 GL-2149-012918
 IN-LAB WORKING TIMES TERMS AND WARRANTY INFORMATION

Please allow full working time for each product selected. Working times are NOT guaranteed and do NOT
include weekends or holidays. Rush service available on most products but must be prescheduled (see below). All Restorations Made in the USA
Obsidian/Diagnostic Wax-Up.......................... 5 days Partials & Dentures
Obsidian w/ attachments, implants or Metal Frames.................................................... 6 days
over stock abutment............................ 7 days Metal Frame with teeth and wax.................... 11 days
We honor VISA, MASTERCARD, AMEX and DISCOVER.
Screw-retained Obsidian................................. 8 days Metal Partial to finish...................................... 12 days
Custom implant abutment............................... 8 days Occlusion rims/Custom tray............................. 3 days TERMS: Cost of collection of any account will be paid by the customer. All
All-ceramic/Zirconia restorations................... 5 days Denture setup try-in.......................................... 5 days accounts are payable within 30 days of statement date. Accounts not paid
Screw-retained BruxZir with Ti-Base............. 8 days Denture try-in to finish...................................... 5 days within the stated terms will be subject to COD status and a late charge
Full-cast restorations....................................... 5 days Valplast/tcs setup teeth in wax......................... 5 days of 2 percent of the unpaid balance. Prices subject to change without no-
Composite restorations................................... 3 days Valplast/tcs start to completion........................ 7 days tice. Rx must be enclosed with original case submission.
Fiber-reinforced composites........................... 5 days Denture soft liner/acrylic repair or reline........... 5 days
BioTemps Provisionals..................................... 5 days Partial repair/reline............................................ 5 days NO-FAULT REMAKE POLICY: Glidewell Laboratories is pleased to process
With cast-metal substructure........................... 6 days PlaySafe mouthguards/Silent Nite sl............... 4 days all remakes or adjustments at no additional charge if requested within the
With cast-metal substructure over implant....... 6 days TAP/TAP 3/dreamTAP/EMA............................. 5 days warranty period and accompanied by the return of the original appliance.
Screw-retained over implant............................ 6 days Comfort H/S Bite Splint/Nightguards.............. 4 days
LIMITED WARRANTY/LIMITATION OF LIABILITY. For warranty terms
Smile Transitions appliance............................ 7 days Bleach trays/Custom trays/Retainers............. 4 days
and conditions and limitation of liability, visit glidewelldental.com/
Transition Crowns & Bridges.......................... 6 days
policies-and-warranties/.
All rush cases must be prescheduled by calling 800-944-7874 before
the case is shipped. Time of pickup and delivery may affect turnaround time.

PREPARATION GUIDELINES PREPARATION GUIDELINES

OBSIDIAN TO METAL ANTERIOR OBSIDIAN TO METAL POSTERIOR OBSIDIAN TO METAL -

CERAMIC LABIAL OR 360° MARGIN

1.25 mm gingival reduction using

rounded shoulder margin design

ALL-CERAMIC/COMPOSITE VENEERS INLAY ONLAY ALL-CERAMIC/COMPOSITE CROWNS

Labial
Lingual 1–1.5 mm
Interproximal

Incisal 1.5–2 mm

Labial
Lingual 1–1.5 mm
A. 1.5 to 2 mm occlusal reduction Interproximal
B. Round all sharp line angles and occlusal edges, and eliminate undercuts.
Occlusal 1.5–2 mm
C. Proximal and occlusal walls should have 6–8 degrees taper