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❑ Denture fully edentulous (Kenson teeth standard) Radiographic Markers: ❑ Gutta percha
❑ Barium (20%)
❑ Duplicate denture
DENTURE REINFORCEMENT
Tooth setup: ❑
Ideal ❑ Characterized ❑ Kenson teeth (Included at no extra charge) ❑ Horseshoe cast palate
❑ Copy study model Shade _____________ Mould _____________
❑ Cast mesh 360° wraparound
❑ Copy existing denture ❑ Premium brand teeth (Extra charge may apply)
Signature_____________________________ ❑ Male ❑ Female Age ________ Shade ______ Brand ______ Mould ______ † Pricedoes not include multi-unit abutments and may
vary when original equipment manufacturer (OEM)
Acrylic shade: ❑ G1 (Standard) ❑ Name on appliance (Additional charge)
License #_____________________________ __________________________________________
components are requested or required for the chosen
Ethnic: ❑ G3 (Med) ❑ G4 (Dk) implant system. Half of payment is due after first
appointment; half is due at final delivery.
© 2017 Glidewell Laboratories
GL-2285-110617
IMPLANT WORKING TIMES TERMS AND WARRANTY INFORMATION
Please allow full working time for each product selected. Working Only $7 shipping per box each way (contiguous U.S. only;
times are NOT guaranteed and do NOT include weekends or holidays. shipping charge varies for Alaska, Hawaii and Puerto Rico).
Days in Lab
BruxZir Hybrid Bar Implant Prosthesis All Restorations Made in the USA
Bite block������������������������������������������������������������������������������������3
Wax setup reset/implant verification jig��������������������������������������4 We honor VISA, MASTERCARD, AMEX and DISCOVER.
Bite splint.....................................................................................3
TERMS: Cost of collection of any account will be paid by the customer. All accounts are pay-
Final BruxZir prosthesis��������������������������������������������������������������8
able within 30 days of statement date. Accounts not paid within the stated terms will be
Screw-Retained Hybrid Denture subject to COD status and a late charge of 2 percent of the unpaid balance. Prices subject
to change without notice. Rx must be enclosed with original case submission.
Bite block������������������������������������������������������������������������������������3
Wax setup reset/implant verification jig �������������������������������������4 NO-FAULT REMAKE POLICY: Glidewell Laboratories is pleased to process all remakes or
Wax setup to finish�������������������������������������������������������������������10 adjustments at no additional charge if requested within the warranty period and accompanied
by the return of the original appliance.
Fabricate CAD/CAM titanium framework�����������������������������������7
Final transfer of setup onto titanium framework������������������������5 LIMITED WARRANTY/LIMITATION OF LIABILITY. For warranty terms and conditions and
Process acrylic and denture teeth onto framework�����������������10 limitation of liability, visit glidewelldental.com/policies-and-warranties/.