LAB USE ONLY, PLEASE DO NOT WRITE IN THIS BOX

LAB USE ONLY, PLEASE DO NOT WRITE IN THIS BOX

IMPLANTS - PRESCRIPTION FORM

DOCTORS NAME:
Phone: Address: Email:

PAN# METAL WEIGHT:

PATIENTS NAME: DUE DATE:
EMERGENCE WIDTH

No tissue displacement (default)

CASE# SHIP:

by 12:00pm by 05:00pm

Hold case (pictures will be emailed for approval) Ship to (if different from prescriber):

Process case (case will be started immediately)

Tissue displacement (medium circumference abutment design) Surgical placement (largest circumference abutment design)

ALLURE Tooth # Implant type Size Stock Abutment

ATLANTIS

STRAUMANN

3i ENCODE B/L

Margins D M L

Screw Retained Titanium Zirconia Titanium Zirconia Gold Hue Titanium Zirconia Titanium Gold Hue Zirconia

DUPLICATE GEMINI ABUTMENT?

YES

NO

SEATING JIG
PONTIC DESIGN METAL DESIGN

TEMPORARY

FINAL RESTORATION TYPE FULL GOLD CROWN

2% AU TYPE IV N 40% AU TYPE IV N 60% AU TYPE III HN

CUSTOM SHADE
STUMP SHADE: __________ DESIRED SHADE: ________

SHADE:

______________________________________________________________

Screw Retained CAD Over Temporary Abutement

ALL CERAMIC

PFM

Zirconia Non-Precious E.MAX Semi-Precious (Noble) Empress Crown/Veneer High Noble White

TEETH NUMBER REMOVABLE AND FIXED REMOVABLE

MARGIN DESIGN
10 23 11 22 12 21 13 20 14 19 15 18

Guided Surgery

STEP 1
Scan Template: Partially Edentulous 1-8 Teeth Fully Edentulous 9+ Teeth From Existing Denture Diagnostic Tooth Setup Celera Impression Technique

Locator attachment implant overdenture Ball attachment implant overdenture CAD/CAM Titanium bar / Acrylic Hybrid CAD/CAM Titanium bar / Ceramic Hybrid Procera Zirconia bridge (cemented) Procera Zirconia bridge (screw retained) Immediate Denture Custom Tray

1 32

5 28

6 27

7 26

8 25

9 24

31 30 29

Show no metal 360 16 All porcelain facial margin All porcelain margin 360 Metal to margin 360 17 Show no metal (traditional PFM)

EXTRA INFORMATION
SURFACE TEXTURE OCCLUSION STAIN

In occlusion Out of occlusion Die spacer on opposing

Smooth Moderate Heavy

None Light Medium Dark

Will opposing teeth be restored in near future? Yes No If inadequate clearance: Spot opposing Call me

STEP 2
Plan: Doctor Plans Case Allure Dental Studio Creates Proposal* Email Address
*Doctor must approve final plan

STEP 3
Surgical Guide: Straumann Other Manufacturer* Size
*Does not include Depth Control

Reduction coping

ADDITIONAL INSTRUCTIONS AND COMMENTS:

Signature:

License Number: