from:

By signing above, I acknowledge that this represents the full complete Agreement between parties. This Agreement is subject to the terms /conditions set forth on the reverse side hereof and such terms and conditions are hereby incorporated in their entirety into the agreement.

DR’S SIGNATURE DR’S LICENSE #

d r a k e - Y O U R L A B O R A T O R Y R E S O U R C E PF9/18Made in the U.S.A

PF 9/18

Virginia Use ONLY Instructions GD60-18: ◊ Domestic Lab Approved ◊ Contact Me Before Subcontracting◊ Overseas Lab Approved◊ Either Domestic or Overseas Lab Approved

8510 Crown Crescent CtCharlotte, NC 28227704 845 24011 800 476 2771www.drakelab.com

PATIENT’S ID: AGE: SEX: DUE DATE:

DATE

IMPORTANT INFO FOR THE LAB:

* Default unless otherwise speci�ed

Enclose with case or email them to drakeqc@drakelab.comCASE PHOTOS:

FINAL SHADE FOR CROWN / BRIDGE / DENTURE:

STUMPF SHADE FOR FIXED METAL-FREE:

T ISSUE SHADE FOR GINGIVAL:

TOOTH SHADE FOR DURATEK:

Case Disinfected?

IF NO OCCLUSAL CLEARANCE:

Trim OpposingReduction CopingOther___________

1

2

3

4

5

67 8 9 10

11

12

13

14

15

16

1732

18

19

20

21

2223242526

27

28

29

30

31

M E TA L F R E E

*

Elite Solid ZirconiaValue Solid ZirconiaZ-Sthetic (Ceramic Coverage)Celtra (Press)e.Max (Press)EmpressCeltra (Milled)e.Max (Milled)

Comfort Zone Comfort Zone Plus Hard Acrylic Night GuardSoft Night GuardDream TAP Snore GuardTAP III Snore GuardEMA Snore Guard

G U A R D / S L E E P

DuraTek Solvay Ultaire Valplast Acrylic Cast Metal Unilateral Frame Try-In Bite Rim Wire Clasps Set-Up Process & Finish

PA RT I A L ELITE or VALUE

Traditional Denture Digital Denture Custom Tray Bite Rim Set-Up Process & Finish Reset Reline

D E N T U R E ELITE or VALUE

P F M Tradition High Noble Tradition Noble Value Noble Value Base

*

F U L L C A S T Tradition HN Yellow Value Noble Yellow Value Noble White

*