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SPECIFIC INSTRUCTIONS :
Dr. Signature License #
FIXED RESTORATIONS (Please )
REMOVABLE RESTORATIONS (Please )
DenturesCustom TrayBase Plate/Wax RimCombo Tray w/ Wax RimEconomy DentureDeluxe DenturePremium DentureTransitional DentureImmediate DentureDenture Set-UpDenture Finish
Metal Partials
Flexible Partials
Standard PartialDeluxe Partial (Vitallium 2000)Frame Try-InWax Try-In with TeethBite BlockFinish
ValplastFRS FlexibleSet-UpFinish
TM
TM
Specialty PartialsAcrylic Partial FlipperAcrylic Partial w/ ClaspUnilateral (NESBIT)FRSValplastMetal / Acrylic
TM
Specialty ProductsDeluxe GuardHard Clear NightguardProForm NightguardBleaching TrayCT Scanning DeviceVacuum Nightguard
Repairs / Relines
HardRelines
Soft
ToothClasp
RepairsFractures
Shade
LucitoneDeluxeEconomyDark
AcrylicPinkMeharry
Flexible
Tooth Shade
Tooth Mold
Tooth Make
Doctor’s Name (Please Print)
Doctor’s Address
Patient’s Name Sex Age
M F
Rx Date :
Date Due in Office :
(Deliver By 5PM)
5606 Randolph Road Rockville, MD 20852Office : 301-230-9060 Fax : 301-230-9063
Emergency : 301-442-0690Email : [email protected]
Website : www.onnikdentallab.com
Onnik Dental Lab, Inc.
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LOWER
Metal Coping
Metal Lingual
3/4 Metal lingual
Metal Coping
Metal Occlusal
Metal Occlusal
All porcelain coverage
Excluding buccal cusp
Including buccal cusp
Metal Margin
Porcelain Margin
Metal Porcelain
Hairline or ____ mm
Junction Margin
Buccal MarginPosteriorsAnteriors
PFM Full Cast MetalNon-PreciousSemi-PreciousHigh NobleCaptek
Full Cast Yellow GoldFull Cast White GoldFull Cast Non-PreciousFull Cast Semi-Precious
All CeramicLava ZirconiaIPS EmpressVeneerIn (On) Lay
ENCLOSURES Lab Use Only
Photo(s) Analog Models Implant PartsImpression Bite Shade Tab Other
PLEASE SEND RX Forms Boxes Mailing Labels
