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843 Quince Orchard Blvd. Ste C&D Gaithersburg MD, 20878 Ph: 240.912.9670 [email protected] www.lintecdental.com Doctor’s Name: Address Phone # Acct # Email Address Paent’s Name: Age Female Male Deliver by 5 p.m. on Review Time: Enclosed with case: Impressions Models Bite Photos Other: Crown & Bridge Paral Crown Implant Provisional Restoraons Zirconia Full Contour Zirconia Layered E.max Zirconia E.max Gradia (Composite) Screw-Retained Zirconia Full Contour Zirconia Layered Cement-Retained Titanium Abutment Zirconia w/Ti Base Abutment Zirconia Full Contour Crown Zirconia Layered Crown E.Max Crown Cement-retained Screw-retained Abutment #(s) Ponc #(s) . Total units Provisionals Reinforcement: None Wire Fibe Occlusal Staining None Light Medium Dark Ponc Design Doctor’s Name: Signature License #: Occlusal Contact In occlusion Light occlusion Out of occlusion Abutment Emergence Profile Surgical placement Tissue displacement No Tissue Displacement Fixed Addional Notes SHADE
