Crown & Bridge Rx PFM MARGIN DESIGN

Laboratory Procedure Prescription Please circle your choice(s) of margin combination for PFM

REQUIRED INFORMATION *

Doctor Name _______________________________________________________

Last First

Practice Name_______________________________________________________
Show no All porcelain Metal collar Facial Lingual Metal Metal
metal 360°* shoulder 360° 360° porcelain metal collar occlusal lingual
Show No Metal
Show Show
No 360
NooShow
Metal Metal
360o All
Show
No
360
Porcelain
Metal
Show
o No
All Show
Metal
360
All
NoShoulder
Porcelain
Metal
No
Porcelain360
Metal
All
o360
Porcelain
360
o360
ShoulderShoulder
Allo360 Metal
o Porcelain
All
o Porcelain
Shoulder
All
360 Collar
Porcelain
Metal Metal
o Shoulder
360 360
Shoulder
Collar Collar
o360Metal
oShoulder
360 o360 360
Metal
Collar
o Facial
o360 Metal
FacialCollar
360
Metal
Collar
o 360
oo Porcelain
Facial Collar
Porcelaino360o360
Shoulder
Porcelain
Facial Facial
Porcelain
180
oShoulder
ShoulderFacial
Porcelain
Facial
o180 Porcelain
Shoulder
180
Porcelain
o Shoulder
180
Shoulder
oShoulder
180 o180 o180 Metal Occlusal
Metal Metal Occlusal
Occlusal Metal
mm. Metal
Occlusal
Metal
Metal
Occlusal
Metal
Lingual
Occlusal
Metal Metal
Occlusal
LingualLingual
Metal Me
Lin
Address_____________________________________________________________
o Lingual Metal
Lingual Lingual
Collar
Metal Metal
_____
Lingual
Collar Collar
mm.
_____Lingual
Metal
o _____
mm. Lingual
Collar
Metal
Lingual
mm.Metal
_____
Collar
Metal
Collar
mm.
_____
Collar
_____
mm.
_____
mm.
shoulder 180° (traditional)
o

Phone_______________________________________________________________ CROWN DESIGN

Patient Name________________________________________________________ Characterizations Pontic Design

Patient Chart #______________ □M □F DOB______________________ P4 P5 P1 P2 P3

*
Rx Date___________________ Due Date/Delivery on___________________
(standard working time if no date given)

Case turnaround times are based on the date the Rx is received at DDS Lab. Please allow

Modified
ridge-lap

Full ridge-
lap

hygienic

Conical
Sanitary/

Ovate
10 business days (M-F) from that date and 15 business days for complex cases.

CASE INSTRUCTIONS
Please CIRCLE single units and BRACKET splinted units Tooth Shade____________________ Shade Guide Used________________
(REQUIRED) (vita is default)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Stump Shade___________________ Pink Tissue Shade________________
(REQUIRED FOR E.MAX)
PFM Metal-Free

□ White HN* □ Zirconia Solid

If Insufficient Room Occlusal Contact Interproximal Contact
(not recommended
□ Semi-precious for anterior) □ Trim opposing* □ Light* □ Light*
□ Non-precious □ Zirconia Layered □ Call to discuss □ Open □ Medium
□ Yellow HN (for PFM) □ High Translucent □ Metal occlusal □ Tight □ Heavy
(max 3 unit bridge)
□ Reduction coping
□ □ Resin* □ Metal
Solid lingual with
□ Metal island
Full Cast
□
porcelain facial
□ Trim prep
□ Full cast Yellow HN gold IPS e.max® Press no coping
□ Full cast Yellow noble (2% AU) (max 3 unit bridge)
□ Full cast White HN □ Lithium Disilicate RX SPECIFIC INSTRUCTIONS
□ Composite crown
□ Full cast Semi-precious Please provide any photos, study models, diagnostic casts with case
□ Full cast Non precious Other Email photos to: ddslabpix@ddslab.com
□ Diagnostic wax-up **The person signing this form is an authorized signer and, along with the dental practice, accepts
□ Clear stent responsibility for payment of all related charges, as well as any legal costs, collection and other fees

□
incurred by DDS Lab in the event the account is sent to collections or litigation.
Putty matrix
□ Temporary _____________________________________________________________________
□ Temporary w/ metal
_____________________________________________________________________

Return for Restoration _____________________________________________________________________

□ Finish* □ Crown □ Post & core _____________________________________________________________________
□ Die trim □ Bridge □ Diagnostic wax-up
□ Bisque □ No-prep veneer □ Rest seats Dentist signature**__________________________________________________
□ Metal try-in □ Veneer (specify)___________________ (REQUIRED BY LAW)

□ Inlay/Onlay □ Crown under partial Dentist license no.__________________________________________________

□ Implant (specify)___________________ (REQUIRED BY LAW)

*Standard design if an option is not selected

5440 Beaumont Center Blvd, Suite 400 | Tampa, Florida 33634 | (877) 337-7800 | www.ddslab.com | DL 10334
© 2021 DDS Lab. All rights reserved.