FINE DENTAL ART PRIVATE STANDARD Shade Mould Surgery Use Only Are impressions Disinfected Yes No Initial Instruction / Amendments: ACRYLIC / CHROME / ORTHO CASE NO. (Lab use only) Prescribing Dentist Name and Address, Telephone (PLEASE STAMP BOTH SHEETS) Patient: (Custom made device for the exclusive use of this patient) Male Female Age DELIVERY DONE TECH DATE DISINFECT Models SP/Tray Bite Try-in Re-try Finish (Lab use only) Approved for manufacture by: Lab Comments: TECHNICIAN CHECKLIST I read and understand the instructions Try 1. Re-Try 2. Re-Try Finish ail: info ntallab. WESSEX DENTAL LAB Eat, Smile, T alk with Confdence Keep away from extreme hot and cold. Non sterile appliance. This device conforms to the relevant essential requirements as set out with Annex 1 of the medical Devices Directive (93/42/EEC). Any relevant essential requirements not met and reason why are listed overleaf. Registration number of manufacturer with the Medicak Devices Agency is CA 002245 Unit 10, Holes Bay Park Sterte Avenue West Poole, Dorset BH15 2AA Telephone: 01202 674486 | Email: info@wessexdentallab.com | www. wessexdentallab.com
Transcript
FINE DENTAL ART PRIVATE STANDARD
Shade Mould
Surgery Use Only
Are impressions Disinfected Yes No Initial
Instruction / Amendments:
FINE DENTAL ART PRIVATE STANDARD
Shade Mould
Surgery Use Only
Are impressions Disinfected Yes No Initial
Instruction / Amendments:
ACRYLIC / CHROME / ORTHO
CASE NO. (Lab use only)
Prescribing Dentist Name and Address, Telephone (PLEASE STAMP BOTH SHEETS)
Patient: (Custom made device for the exclusive use of this patient)
Male Female Age
DELIVERY DONE TECH DATE DISINFECT
Models
SP/Tray
Bite
Try-in
Re-try
Finish
(Lab use only) Approved for manufacture by: Lab Comments:
TECHNICIAN CHECKLIST I read and understand the instructions
Try 1. Re-Try 2. Re-Try Finish
ACRYLIC / CHROME / ORTHO
CASE NO. (Lab use only)
Prescribing Dentist Name and Address, Telephone (PLEASE STAMP BOTH SHEETS)
Patient: (Custom made device for the exclusive use of this patient)
Male Female Age
DELIVERY DONE TECH DATE DISINFECT
Models
SP/Tray
Bite
Try-in
Re-try
Finish
(Lab use only) Approved for manufacture by: Lab Comments:
TECHNICIAN CHECKLIST I read and understand the instructions
Keep away from extreme hot and cold. Non sterile appliance. This device conforms to the relevant essential requirements as set out with Annex 1 of the medical Devices Directive (93/42/EEC). Any relevant essential requirements not
met and reason why are listed overleaf. Registration number of manufacturer with the Medicak Devices Agency is CA 002245
Keep away from extreme hot and cold. Non sterile appliance. This device conforms to the relevant essential requirements as set out with Annex 1 of the medical Devices Directive (93/42/EEC). Any relevant essential requirements not
met and reason why are listed overleaf. Registration number of manufacturer with the Medicak Devices Agency is CA 002245
Unit 10, Holes Bay Park Sterte Avenue West Poole, Dorset BH15 2AAUnit 10, Holes Bay Park Sterte Avenue West Poole, Dorset BH15 2AATelephone: 01202 674486 | Email: [email protected] | www.wessexdentallab.comTelephone: 01202 674486 | Email: [email protected] | www.wessexdentallab.com
99614 Wessex Dental Surgery Order Pads NCR.indd 1 18/03/2016 15:50
