Dentist Profile Form Generic - Dental Services Group DENTIST PROFILE FORM Dentist Name License Number

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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 GP Prostho Ortho Oral Surgery Perio

    M T W R F

    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 PROSTHODONTICS MARGINS 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 Coping Spot/Adjust Opposing Call For Instructions

    Broad Normal Point

    Smooth Medium Heavy

    CONTOUR

    STAINING

    Match Patients Dentition YES NO Make Ideal YES NO

    None Normal deviation in color of anteriors Pit and fissure Exact duplication of shade tab Characterization stain on anteriors

    BASE PLATE LINGUAL RELIEF POST DAM PALATAL RELIEF SET UP FINISH

    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 Classic Other:

    & Festoon

    TRY IN RELIEF 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