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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 [email protected]. 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