(757) 622-4614
rbise@virginiadentallab.com
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Digital Prescription Form
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Digital Prescription Form
Doctor
Date
Address
Patient
Age
Date Wanted
Time Wanted
Design Your Case:
Shade desired:
REMOVABLE RX
COMPLETE DENTURES
Standard Denture
Success Injecction Denture
PARTIALS
Cast (Complete):
Classic Cast Partial
Premium Cast Partial
Framework Only
Acrylic (Complete):
Classic Partial
Premium Partial
Flexible (Complete):
Classic Flexi
Premium Flexi
TEETH TYPE
Classic
Premium Shade Ant.
Post.
Mold Ant.
Post.
ADDITIONAL PRODUCTS
Baseplate with Bite Rim
Light Cured Custom Tray
Nightguards:
Hard
Soft
Repairs:
Acrylic Fracture
Additional Tooth
Reline
Rebase
Laser Weld
Add Clasp
Metal Mesh
Lingual Bar
FIXED RX
PORCELAIN FUSED TO METAL
High Noble Yellow Gold
High Noble White Gold
Noble (Semi Precious)
Base Metal (Non-Precious)
METAL-FREE
e-Max
e-Max Veneer
Elite Zirconia (Layered)
Full Z (Contoured)
FULL-CAST CROWN-INLAY-ONLAY
Type II Yellow High Noble (Inlay)
Type III Yellow High Noble (Inlay)
Type IV Yellow or White: High Noble or Noble
Base Metal (Non Precious)
MARGINS
Lingual
Show No Metal
Metal Collar (Thick)
Metal Collar (Thin)
Porc.Butt (Shoulder) 180
Porc.Butt (Shoulder) 360
Facial
Show No Metal
Metal Collar (Thick)
Metal Collar (Thin)
Porc.Butt (Shoulder) 180
Porc.Butt (Shoulder) 360
PONTIC DESIGN
A
B
C
D
E
OCCLUSAL STAIN
None
Light
Medium
Dark
IF NO OCCLUSAL CLEARANCE
Call Doctor
Adjust opposing tooth
Metal occlusion
Instructions:
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(757) 622-4614