ORDER FORM

PLEASE FILL IN THIS ORDER FORM WITH ALL DETAILS SO THAT WE
CAN DELIVER IT IN BEST QUALITY THAT YOU HAVE DESERVED
Name/Surname
Patient
Details Of Patient
Male Female
Age..:
Type..:
Degree Date
Crown Proof
Framework Proof
Dentin Proof
Wax Set-Up Try-Inn
Ending
CODES OF WORKS
Porcelain = P Full Crown = F Express Crown = E Inlay = I
Onlay = O Procera = Pr Acrylic = B Telescope = T Provisonal = G
PLEASE, STATE THE TRANSACTION OF THE TOOTH / TEETH
18171615 14131211 21222324 25262728
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
METALL
Non-Valuable Metall Nickel-Free Nickel
Valuable Metall
Number Of Tooth
Single Crown
Blocked Crown
Poskor
Color Of Tooth Col
Bridge
GIVE SHAPE TO THE BRIDGE
With Metallband
Without Metallband
Full Aesthetic
Metallbant On Lingual
Circelled Metallband
Foil By Closure
Aproximal Contacts Fast
Aproximal Contacts Loose
Framework
Upper Framework
Lower Framework
Clasp
Hook
Upper Artificial Teeth
Lower Artificial Teeth
Upper Complemention
Lower Complemention
Upper Wax Closure
Lower Wax Closure
Transversalframe
Horseshoe
Skeleton Model
Attachment
Tooth Number
Sort
Ancorvis
Geschiebe
Anker
Steg
Riegel
Special Request And/Or Notes :