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800.259.3717 www.dentalservices.net

In an effort to consistently produce to your individual preferences, please complete and return to us with your first case or via fax or email to info@dentalservices.net. This profile will be entered into our computer system and be available each time you send us a case. In the event that you need to deviate from this profile, simply indicate it on your prescription. Please feel free to use the space on the back of this form for any additional information to communicate to us.We look forward to working with you!

PLEASE CHECK SPECIALTY OFFICE DELIVERY HOURS

GPProsthoOrthoOral SurgeryPerio

MTWRF

How do you prefer we reach you for technical questions & follow up?

Office phone Drs Cell Phone Drs Email

DENTIST PROFILE FORM

Dentist Name

License Number

Street Address

Office Contact (Name + Title)

Practice Name

Office Phone

City

Email Address

Group Name

Dr Cell Phone

State, Zip

Dr Email

FIXED PROSTHODONTICSMARGINS AND COLLARS

Lingual Metal Collar

Full Metal Collar

Metal Occusal,Exclude Buccal Cusp

Metal Occlusal,Include Buccal Cusp

Full Porcelain Coverage

Full Coverage Lingual

2/3 Coverage Lingual

Full Metal Lingual

3/4 Metal Lingual

1/4 Metal Lingual

PONTIC DESIGN

Sanitary Full Ridge Modified

Bullet Ovate

DIES TRIMMED BY

DIE SPACER

POST & CORE

OCCLUSION

INSUFFICIENT CLEARANCE

CONTACT AREA

SURFACE TEXTURE

Doctor Lab

None Light Medium Heavy

Post & Core as one unit Post seperate

Ideal Slightly out Tight

Metal Occlusion Reduction CopingSpot/Adjust Opposing Call For Instructions

Broad Normal Point

Smooth Medium Heavy

CONTOUR

STAINING

Match Patients Dentition YES NOMake Ideal YES NO

None Normal deviation in color of anteriorsPit and fissure Exact duplication of shade tabCharacterization stain on anteriors

BASE PLATELINGUAL RELIEFPOST DAMPALATAL RELIEFSET UPFINISH

BORDER EXTENSION

TOOTH PREFERENCE

Processed Light Cured Vaccum Formed

Light Normal Heavy

Moustache Butterfly Bead Other

Yes No

Ideal Characterized Per Study Model

Stipple Smooth Rugae Relieve undercuts

Full As marked Laboratory Discretion

Dentsply: Portrait IPN Bioform ClassicOther:

& Festoon

TRY INRELIEF FOR LOWER LINGUAL BARS

DESIGN

PREFERRED UPPER DESIGN

CLASP MOST DESIRED

CLASP RETENTION

TOOTH PREFERENCE

Metal Bit on frame Wax set up Finish

Heavy Light Moderate

AP Bar / Circular / Double Bar

Horseshoe

Palatal Strap Full Palate

All Metal with Backings & Veneers

Full Mesh Strengthener

Full Metal Coverage

Acrylic Post Dam Area

Smooth Palate

Follow Rx

Lingual Bar

Full Lingual Plate/Apron

Lingual Bar and Kennedy STrap

Lingual Bar and Indirect Retainer

All Metal with Backings & Veneers

Strengthener Bar

DE Hinge

Follow Rx

Follow Rx exactly

Modify design as required

Reduce opposing as required

Modify clasp type, not tooth

Call for all design modifications

PREFERRED LOWER DESIGN

FRAME CONNECTOR SIZE

FINISH MOST DESIRED

Danity Standard Heavy

Lucitone 199 Acrylic Flexible Acrylic

Saddle Lock “Hidden Clasp”

Roach/T-Bar

Modified Roach

Esthetic Clasp

Flexible, Clear

Flexible, Tooth Shade

I Bar

Back Action/Ring

Akers/Circumferential

Regular Heavy

Portrait IPN Bioform Classic

REMOVABLE FULL DENTURE

REMOVABLE PARTIAL DENTURE

NOTES