PLUS DENTAL DIGITECH
ORDER FORM
CROWN & BRIDGE
PRACTICE NAME
*
DENTIST NAME
*
First Name
Last Name
PATIENT NAME
*
First Name
Middle Name
Last Name
AGE
GENDER
Please Select
Male
Female
CREATE DATE
*
-
Month
-
Day
Year
Date
RETURN DATE
-
Month
-
Day
Year
Date
APPOINTMENT
-
Month
-
Day
Year
Date
TOOTH NUMBER(S)
RESTORATION TYPE
*
Crown
Bridge
Inlay/Onlay
Veneer
Post & Core
Maryland Bridge
Diagnostic Wax Up
Implant Screw-Retained (Direct to Fixture)
Implant Cement-Retained
Customised Abutment
Other
IMPLANT MANUFACTURER
Company, Brand
IMPLANT TYPE
Diameter, Platform type
MATERIAL TYPE
*
Layered Zirconia (Porcelain Veneered)
Monolithic Zirconia (Full Contoured)
Layered EMAX (Porcelain Veneered)
Monolithic EMAX (Full Contoured)
PFM (Porcelain Fused to Metal)
Full Gold Crown
Full Metal Crown
PMMA Temporary Crown
Other
ALLOY TYPE (IF REQUIRED)
Non-Precious
Semi-Precious
Yellow Ceramic Gold for PFM
Yellow Cast Gold for Gold Crown
Other
SHADE
FILE/IMAGE UPLOAD
Browse Files
Drag and drop files here
Choose a file
Cancel
of
INSTRUCTION/COMMENT
Print
Save
SUBMIT
Should be Empty: