METAL-FREE PARTIALS� Flexible Partial � Valplast

Select Stage:� Complete (One Stage)� Wax-up w/Teeth � Process/Finish

ACRYLIC PARTIALS� Flipper (1 Tooth)� Stayplate* (2-5 Teeth)� Acrylic Partial* (6+ Teeth)*Includes wire clasps

IMMEDIATES� Extract All

� Extract Tooth # _______

CAST METAL PARTIALS� Chrome Cobalt � Vitallium 2000

Select Stage:� Complete (One Stage)� Frame Try-in � Set to Enclosed Frame � Wax Try-in w/Teeth � Final Process

SELECT: � Full Denture � Partial � Unilateral � Upgrade to Premium Teeth

MAJOR CONNECTOR

��� Lab Select

�� Full Palate

�� Horseshoe

�� Lingual Bar

REMOVABLE EXTRAS� Wax Bite Block

� Wax Bite Rim

� Custom Tray

� Bleach Tray

SPORTS GUARD

� Pro-Form Sports Guard

BITESOFT SPLINT THERAPY(Upper Arch only)

�� Anterior Splint ��� Full ArchSelect Material: ��� Dual Laminate ��� Thermo-lined

FULL DENTURES� Standard � Premium

Select Stage:� Complete (One Stage)� Wax-up w/Teeth � Process/Finish

CLASP DESIGN��� Lab Select ��� RPI

��� Roach ��� Akers

�� Palatal Strap

�� Lingual Plate

��� A-P Bar

� Rebase

� Reline Hard

� Reline Soft

� Cusil #

COMBO PARTIALS� Vitallium 2000 w/Flexible Partial

� Vitallium 2000 w/Valplast Select Stage:� Complete (One Stage)� Frame Try-in � Set to Enclosed Frame � Wax Try-in w/Teeth � Final Process

NIGHT GUARDS� Hard � Soft � Hard/Soft

CASE MATERIALS ENCLOSED:�� Impressions �� Bite Registration �� Models �� Implant Parts

CROWN & BRIDGE

REQUIRED INFORMATION

REMOVABLE

� ACRYLIC TEMPORARY�

SPECIAL INSTRUCTIONS

IF INSUFFICIENT ROOM� Adjust Opposing� Reduction Coping� Metal Occlusal / Lingual � Please Call

CONTACT� Broad � Point

CROWN & BRIDGE CASE SPECIFICATIONS

SELECT STAGE:

METAL DESIGN

BUCCAL MARGIN � Porcelain Butt Margin � 3600 Porcelain Butt Margin

PONTIC DESIGN

OCCLUSAL CLEARANCE� Light � Open � Tight

IMPLANTS (Servicing all major implant brands)

� Stock � Custom � Parts Supplied by Doctor

Size _______________________

Manufacturer ________________

SELECT: � Crown � Bridge � Inlay/Onlay � Veneer

ZIRCONIA� Full/Solid Zirconia � Zirconia Layered� BruxZir Solid Zirconia� BruxZir Anterior Solid Zirconia

� COMPOSITE

PFM� Non-Precious� Semi-Precious� Captek� White Gold� Yellow Gold HN� Maryland Bridge

� NP � SP ALL-CERAMIC� IPS e.max CAD � IPS e.max Press � IPS Empress

FULL CAST � Non-Precious � Semi-Precious� Gold 46%� Gold 60%� White Gold� Yellow Gold HN

2629 Manhattan Avenue, #279Hermosa Beach, CA 90254-2447

(866) 366-7070Fax (866) 366-7060

sales@dentallabconcepts.comwww.dentallabconcepts.com

STAINING� Light � Medium � Heavy � None

C&B EXTRAS� Rest� Wing� Fit to Partial� Diagnostic Wax-Up

FOR LAB USE ONLY

TISSUE SHADE: � Pink � Ethnic� Light Pink

� MTI / Coping � Bisque Bake � Finish

� Complete � Porcelain Bake � Glaze / Polish

TOOTH #: ____________

Account #: ______________ Rx Date:____________

Due Date (by 5 pm): ___________________________

State: ______ Zip: __________

Patient’s Name: ______________________________ Select: � M � F

Email: _____________________________________

Company/Doctor: ________________________ Lic.#___________

Address: ______________________________________________

City: _________________________________________________

Phone: _______________________________________________

Authorized Signature*: __________________________________

UPPER

LOWER

CIRCLE TEETH / ARCH

SHADE:______________

STUMP SHADE:_______

(Standard Working Timesif no due date provided)

� Light � Medium � Heavy

REQUEST SUPPLIES:�� Rx Forms �� Case Boxes �� FedEx Labels

Redo Reason:

Call Today for a Case Pick-up! (866) 366-7070

�� Open Margin�� Open Contact

�� Shade Off�� Bite Off

�� Redo �� Correction �� DLC Case # ______________________

�� Fractured�� Other: ____________________________

DENTAL LABORATORY CONCEPTS TERMS & WARRANTY*By signing or sending this Rx slip (or a substitute therefore) to Dental Laboratory Concepts (d.b.a. DLC), I agree to abide by all terms and policies listed below.

TERMSAll statements must be paid in full by the 22nd of the month in which the statement is prepared. Any amounts not paid by the last business day ofsuch month will incur a 2% finance charge per month, and the account will be automatically placed on C.O.D. terms. All cases will be billed in stagesand will be paid in full according to stage. All cases and items sent remain the property of Dental Laboratory Concepts, until client’s account is paidin full. All disputes shall be governed in all respects by California law and client agrees to submit to the exclusive jurisdiction of, and venue in theCounty of Los Angeles, State of California in any dispute, with the prevailing party to recover attorney’s fees, court costs and other expenses, including actual expert witness fees, if any, in addition to any other relief to which prevailing party may be entitled.

Warranty begins on delivery date. This warranty is in lieu of all other warranties, whether expressed or implied and may not be modified by anyagent, employee, representative or distributor of Dental Laboratory Concepts.

* All warranty terms and conditions are subject to change without notice. Please visit www.dentallabconcepts.com to receive a complete list of warranty terms & conditions.

* All prices are subject to change without notice and are quoted as complete (one stage) or one unit. Some products are subject to additional fees, e.g., C & B and removable extras, attachments and additional implant parts, multiple stages, and metal surcharges.

� Wire reinforcement will be added to each Temporary 3-unit bridge at an additional $10.

Discount terms are subject to change without notice. All discounts will be applied to promoted product and current pricing.

TURNAROUND TIMES (Days Inlab) �

Crowns & Bridges/Removables 7-10 days inlabImplants^ 10 days inlab^ Additional time may be required to order parts. � Weekends & holidays excluded. Working times are not guaranteed.

DELIVERIES (Monday - Friday)All cases are delivered via express courier the next business day (by 5 pm). Additional time may apply to outlying areas. Excludes Alaska, Hawaii and International.

DLC RX REV. 06/26/2018

Please Note: A case requiring a call from the scheduling department or technician for case questions regarding incomplete information provided, may cause delays to the fabrication process.

RUSH FEES“RUSH 25” - 4 Business Days InLab Add $25.00 per unit“RUSH 55” - 3 Business Days InLab Add $55.00 per unit

Rush services/fees are not available for all products and subject to change during holidays. Rush cases must be pre-approved. To arrange rush service for your case,contact DLC Customer Service. Rush fees not subject to credit.

Date Type of Exam Dr. Initials

*For eligible remakes within 30 days but without the original case, DLC shallremake these cases at 100% of the retail price of the restoration at the timethe request is made. If the original model and dental restoration are returnedwithin 60 days from the original invoice date, DLC will issue a 100% credit tothe customer’s account. Any credit balance on a DLC account must be usedfor lab services within 60 days from the date of issue or it expires.

REMAKE & WARRANTY POLICY*

The cost for fabricating custom made dental appliances cannot be refunded. A credit may be issued by Dental Lab Concepts (DLC) directlyto a customer’s account when cases do not meet DLC 's exceptionalstandards for quality, function and aesthetics.

Warranty of Work*

DLC guarantees its work for one year against defects in materials and craftsmanship. The following appliances and services are not covered by any warranty because of their temporary or delicate nature:

• Acrylic Temporaries• Veneers

*For any type of complete or partial denture (including immediate and premium dentures), no remake nor warranty applies unless the case was fabricated together with a wax try-in.

Warranty Conditions*

1. Prosthesis must be inserted by a licensed practicing dentist.2. Patient must adhere to semi-annual dental maintenance (cleaning and exam) in the office of a licensed practicing dentist.3. The maintenance schedule on this certificate must be documented by the attending dentist each visit to validate this warranty.4. Dental prosthetic must be returned with model work in order for the credit to be issued.

Warranty Coverage Excludes*1. Cash refund for prosthesis.2. Cost incurred for removal or insertion.3. Incidental or consequential damages; including inconvenience, lost wages, chairtime, or pain and suffering.4. Repairs resulting from accident, neglect, abuse, failure of supportive tooth or tissue structures, improper adjustments or dental hygiene.5. Dental Laboratory Concepts is not liable for any fixed prosthetic over 5 (five) units or any removable prosthetic that has not been appropriately

fitted prior to process.6. Repairs, relines, temporaries, implants, immediate dentures or partials, and appliances partially or completely fabricated by another lab other

than Dental Laboratory Concepts.

Remake Policy*

All remakes will be at no charge if received within 30 days of the invoice date except under the following circumstances:

1. DLC inquired about the die, margin or impression. However, the customer approved and requested completion of the case.

2. DLC requested a try-in, but the customer declined and asked for a completed case.

3. The teeth are re-prepared.4. There is a shade change different from the original request.5. The partial denture fits the master cast.

• Complete or Partial Denture (see below)• Premium Denture (see below)

• Acrylic Temporary• Veneer

• Stayplate• Masel Crown

CREATE YOUR ONLINE ACCOUNT - Visit www.dentallabconcepts.com/myaccountTrack your cases, account balance, print case invoices, make a payment and upload digital files in a flash!You must be a DLC customer (Upon receipt of your first case or product purchase) to access the My Account section of the website.

PICK-UP - Call DLC to arrange a case pick-up for next-day delivery.

• DiagnosticWax-Up