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RX Form
(302)345-4995
(302)834-1715
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Date:
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Doctor's Name:
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Patient's Name:
*
Doctor's Address:
Email Address:
*
Phone Number:
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Gender:
M
F
Others
Age:
REMOVABLES RESTORATIONS
Dentures:
Custom Tray
Base Plate/Wax Rim
Combo Tray w/ Wax Rim
Economy Denture
Deluxe Denture
Premium Denture
Transitional Denture
Immediate Denture
Denture Set-Up
Denture Finish
Metal Partials:
Standard Partial
Deluxe Partial (Vitalium 2000)
Frame Try-In
Wax Try-In with Teeth
Bite Block
Finish
Speciality Partials:
Acrylic Partial Flipper
Acrylic Partial Flipper w/ Clasp
Unilateral (NESBIT)
FRSTM
Valplast
Metal/Acrylic
Flexible Partials
ValplastTM
FRSTM Flexible
Set-Up
Finish
Specialty Products
Heat Process Temporaries
Diagnostic Work-Ups
Repair/Relines
Relines:
Hard
Soft
Repairs:
Tooth
Fractures
Clasp
Shade
Acrylic
Lucitone
Deluxe
Economy
Dark
Flexible
Pink
Mehamy
Tooth Shade:
Tooth Mold:
Tooth Make:
Select Tooth Number:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
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