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First name
Last name
Clinic
*
Patient ID
*
Delivery date
*
All on X workflows
Tooth shade.
Gingival shade.
Light.
Medium.
Dark.
chose all that apply
Surgical denture for conversion.
Printed provisional with ti bases.
Printed try-in with printed copings.
Full contour zirconia.
I-bar with zirconia overlay.
I-bar with printed overlay.
MUA brand or type.
MUA conection.
Ti bases.
Direct to MUA. (milled copings)
Crown and bridge
Tooth shade.
Crown type.
Full contour zirconia.
Cutback zirconia with porcelain.
Abutment type.
Custom milled titanium
Ti base.
Please indicate tooth # involved, whether it's an abutment, pontic, or implant, and implant brand. IE: #3 and #5, implant, Straumann bone level RP. #4, pontic.
Instructions.
File upload
Upload File
Jaw relation record has been confirmed.
DR. signature
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