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Sending a Crown/Bridge,
Removable Case
Integrity Dental Services Universal Rx
Doctor Name:
*
Practice Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name (if different from Doctor Name):
Contact Phone Number:
*
Please enter a valid phone number.
Would you like us to Text or Call with case questions?
Text
Call
Email
Patient Name:
*
Email:
*
example@example.com
Tooth Shade
*
Based on Vita Classic shades
Delivery by 5pm: (10 DAYS IN LAB PLUS SHIPPING)
*
-
Month
-
Day
Year
(10 in-lab days)
Stump Shade
Based on Vita Classic shades
Gender
Please Select
Male
Female
Removable
Type of Prosthesis
Upper
Lower
Dentures
Standard Full Denture
Premium Full Denture
Stage
Frame Try-In
Wax Rim
Set-Up for Try-In
Process & Finish
Complete (Set and Finish)
Custom Tray
Partial
Cast Metal RPD
Valpast RPD
Acrylic (temp) RPD
Snow Rock
Immediate Denture/Partial Ext.
Teeth to Extract
Repairs
Type:
Night Guards
Hard/Soft Combo
Hard Night Guard
Soft Night Guard
Crown and Bridge
Ceramic Restorations
Full Contour Zirconia
3D Zirconia
Layered Zirconia
Lithium Disillicate
Implant Restorations
Custom Titanium Abutment
Custom Zirconia Abutment
Encode Abutment and Zirconia Crown
Custom Milled Temporary - Screw Retained
Custom Milled Temporary - Cement Retained
Full Cast C&B
Non-Precious
White Noble
White High Noble
Yellow Golf 40%
Yellow Gold 50%
Yellow Gold 60%
Post & Core
Metal for Post & Core:
PFM Crown & Bridge
Non-Precious
High Noble
Noble
Occlusion
In Occlusion
Light
Out
If No Occlusion Clearance
Metal Occlusion
Adjust Opposing
Reduction Coping
Call for Reprep
Tooth Numbers:
Files, Notes and Signature
Files
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Notes:
Integrity Dental Services needs to contact me before starting the case.
*
Please Select
Yes
No
Rush Case
Please Select
Yes
No
(additional fees may be included)
Signature:
*
Clear
License #:
Lab Code
Print
Submit
Should be Empty: