laboratories glidewell - …hogandentallab.com.r16.millsys.org/wp-content/uploads/2015/04... ·...

Dr. Phone #

Patient

Deliver by 5 p.m. on

Rx

LABORATORY USE ONLY

By ________ Mail ________

GLIDEWELL LABORATORIES4141 MACARTHUR BLVD. • NEWPORT BEACH, CA 92660

800-854-7256 • Toll-free fax 800-411-9722

• FIXED RESTORATIVE RX • Dr. Name

Dr. Account #

Address/E-mail

PORCELAIN FUSED TO METAL ❑ Non-Precious* ❑ Noble ❑ White High Noble ❑ Captek YHN ❑OcclusalGold YHN

*Standard unless specified otherwise

COMPOSITES❑Premise Indirect* ❑Sinfony

❑Fiber Reinforcement

Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑Photos Other:

01-421-0908fixed

See Reverse For In-Lab Times

IMPLANT ABUTMENTS

❑Titanium* ❑Zirconia

Specify system: ❑3i ❑Nobel Biocare ❑Straumann ❑Zimmer

Specify brand:___________________ Specify diameter on Rx

PROVISIONALS ❑BioTemps ❑Transition C&B

Abutment #s________________________________

Pontic #(s)___________________ Total units_____

❑Splinted* ❑Individual units

Reinforcement: ❑None ❑Wire* ❑Fiber ❑Metal

Amount of prep reduction: ❑1mm* ❑2mm

❑Perio treatment: Prepare tooth below gingival

on tooth #(s) ____________ by __________mm

❑Pontic site healing: Prepare ovate socket

on tooth #(s) ____________ by __________mm

IF NO OCCLUSAL CLEARANCE

❑Call Doctor

❑Spot Opposing

❑Metal Occlusion ❑Yes ❑No

Would you like this to be a permanent note in

your master file?

Copyright ©2008 Glidewell Laboratories

FULL-CAST RESTORATIONS

❑ Noble-Cast 45 YN (40%Au) ❑ Non-Precious ❑ Noble-Cast 60* YHN (57.5%Au) ❑ White Noble ❑ Noble-Cast 67 YHN (64%Au) ❑WHN (45%Au) ❑ OcclusalGold YHN (73.8%Au) ❑ Post & Core ❑ JRVT YHN (77%Au)




(First) (Last)

Signature ______________________________________________________ License # ______________________________

❑ check here to manufacture ceramics or full-cast using cad/cam

PORCELAIN FUSED TO ZIRCONIA❑Prismatik Clinical Zirconia* ❑Lava ❑Cercon Procera: ❑Zirconia ❑Bridge Zirconia

ALL-CERAMICS❑Vivaneers No-Prep Veneers* ❑IPS e.max CAD* ❑IPS Empress Veneer ❑IPS e.max Press ❑IPS Empress ❑Procera Alumina❑IPS Empress CAD

Indicate stump or present tooth shade for all-ceramics

PONTIC DESIGN

FINAL CERAMIC SHADE

OCCLUSAL STAINING ❑ None ❑ Light* ❑ Medium ❑ Dark

❑ ❑ ❑* ❑ ❑

MARGIN/METAL DESIGN

❑❑❑❑* ❑

Indicate Shade Here

❑❑❑* ❑

PRESENT TOOTH OR STUMP SHADE

Indicate Shade Here

If No Occlusal Clearance

❑Call doctor ❑Spot opposing

❑Metal occlusion ❑Metal island

❑Make this a permanent note in my master file

Labial Butt 360° Butt Junction Junction ❑ ❑ ❑* ❑

Dr. __________________________________________________________

Patient _______________________________________________________

Date Sent _____________________________________________________

Due Date _____________________________________________________

Enclosed with case: q Impressions q Models q Bite q Photos q Partial Other:____________

Dr. Phone #

Patient


Rx

LABORATORY USE ONLY

By ________ Mail ________


800-854-7256 • Toll-free fax 800-411-9722


Dr. Account #

Address/E-mail






01-421-0908fixed


IMPLANT ABUTMENTS





Abutment #s________________________________






on tooth #(s) ____________ by __________mm


on tooth #(s) ____________ by __________mm


❑Call Doctor

❑Spot Opposing



your master file?







(First) (Last)






PONTIC DESIGN

FINAL CERAMIC SHADE


❑ ❑ ❑* ❑ ❑

MARGIN/METAL DESIGN

❑❑❑❑* ❑

Indicate Shade Here

❑❑❑* ❑


Indicate Shade Here






TERMS: 2% Monthly Service Charge Over 30 Days. Customer agrees to pay full cost of collection plus attorney fees and court costs.

7602 Talbert Avenue, Suite EHuntington Beach, CA 92648

(714) 842-0466 Fax (714) [email protected]

www.hogandentallab.com

OGAN ENTAL

HDLAB USE ONLY

CASE PAN #

SHIP DATE

DENTIST

ANTERIOR METAL DESIGNq No Metal Showing

q Lingual Metal Collar

q Metal Lingual

SHADE INSTRUCTIONS

PONTIC DESIGN ANTERIOR METAL DESIGN

POSTERIOR METAL DESIGN OCCLUSALSTAINING

INSTRUCTION FOR BUCCAL MARGIN

� � � � � � �

� � � ��

� None

� Light

� Medium

� Dark

� Metal hairline or ________mm on buccal� Metal-porcelain junction margin� Porcelain butt margin (90° shoulder required)

ENCLOSED WITH CASE

___ Impression ___ Models ___ Bite

___ Articulator ___ Crown/Bridge

Other _____________________________

LABORATORY PROCEDURE AUTHORIZATIONPLEASE WRITE CLEARLY TO ENSURE PROPER BILLING & SHIPPING

©2007 Glidewell Laboratories

�

�

�

�

Full coverage

Lingual metal collar

Excluding buccal cusp

Including buccal cusp

01-1125-0507

4141 MacArthur Blvd. • Newport Beach, CA 92660Toll-free 800-787-4736 • fax 800-579-8233

Date Sent: ___________________

Date Due: ___________________

Patient/ID: _______________________Lab: ______________________________________

Address: __________________________________

City: ______________________________________ State: _____ Zip: ___________

xSPECIFIC INSTRUCTIONS

TOOTHNUMBER

Signature: ________________________________ Date: ____________I verify that a signed prescription from a licensed dentist is on file for the restoration.

� Prismatik CZ� Lava Zirconia

Dr. Zip Code: ______________(3M Required)

� Cercon Zirconia� Procera Zirconia� Procera Zirconia bridge� Procera Zirconia

Custom Implant Abutment

� IPS Empress� IPS e.max� Wol-Ceram Alumina� Procera Alumina

� BioTemps� Transition C&BAbutment #s ___________________________________Pontic #s _______________Total Units ______________

� Non-precious� Noble (Semi-precious)� White High Noble� Captek YHN� Yellow High Noble � Procera Titanium


PROVISIONALS

ZIRCONIA

ALL-CERAMICS

PORCELAIN TO METAL

INDICATE CORE SHADE BESIDE TOOTH # BELOW

� Coping(s)/Substructure(s) � Unfinished Crown(s) � Finished Crown(s)� Build-up coping(s)/substructure(s) for porcelain support

GLIDEWELLLABORATORIES

SHADE INSTRUCTIONS




� � � � � � �

� � � ��

� None

� Light

� Medium

� Dark


ENCLOSED WITH CASE



Other _____________________________



�

�

�

�

Full coverage




01-1125-0507


Date Sent: ___________________

Date Due: ___________________

Patient/ID: _______________________Lab: ______________________________________

Address: __________________________________

City: ______________________________________ State: _____ Zip: ___________


TOOTHNUMBER










PROVISIONALS

ZIRCONIA

ALL-CERAMICS

PORCELAIN TO METAL




No Metal Showing

Age

_______M / F

OCCLUSAL STAININGq None q Lightq Medium q Dark

POSTERIOR METAL DESIGN

PONTIC DESIGN

OTHER SERVICESq Porcelain Labial Butt Margin (shoulder required)q Metal Try Inq Bisque Bake Try Inq Removal Buttonq Post: Separate / Fixed / Castq Future R.P.D. Rest Mesial, Distal, Cingulumq Partial Adaptionq Precision Attachment M/Fq ERA Attachmentq Splint

PORCELAIN FUSED TO METALHigh Noble Alloys* Noble Alloys* Other Alloysq 40% White Gold q 25% Palladium q Non-Precious q 80% Palladium q No - Nickel* *Additional charges apply

FULL METALq 63% Yellow Gold (HN)*q 2% Yellow Gold (N)*q 80% Palladium (N)*q Non-Preciousq No - Nickel*

IPS E.MAX®

q Veneer q Inlay / Onlay q IPS E.max® Press/Layering Crown

ZIRCONIAq Zirconia with Porcelain Overlay q Lavaq BruxZir® Solid Zirconia (Authorized BruxZir® Laboratory)

Shoulder required • Indicate stump shade

LABORATORY

q Separate Crown

q Bridge

Dr. Phone #

Patient


Rx

LABORATORY USE ONLY

By ________ Mail ________


800-854-7256 • Toll-free fax 800-411-9722


Dr. Account #

Address/E-mail






01-421-0908fixed


IMPLANT ABUTMENTS





Abutment #s________________________________






on tooth #(s) ____________ by __________mm


on tooth #(s) ____________ by __________mm


❑Call Doctor

❑Spot Opposing



your master file?







(First) (Last)






PONTIC DESIGN

FINAL CERAMIC SHADE


❑ ❑ ❑* ❑ ❑

MARGIN/METAL DESIGN

❑❑❑❑* ❑

Indicate Shade Here

❑❑❑* ❑


Indicate Shade Here






360° Metal Margin Thin, 0.5, 1.0 mm

Dr. Phone #

Patient


Rx

LABORATORY USE ONLY

By ________ Mail ________


800-854-7256 • Toll-free fax 800-411-9722


Dr. Account #

Address/E-mail






01-421-0908fixed


IMPLANT ABUTMENTS





Abutment #s________________________________






on tooth #(s) ____________ by __________mm


on tooth #(s) ____________ by __________mm


❑Call Doctor

❑Spot Opposing



your master file?







(First) (Last)






PONTIC DESIGN

FINAL CERAMIC SHADE


❑ ❑ ❑* ❑ ❑

MARGIN/METAL DESIGN

❑❑❑❑* ❑

Indicate Shade Here

❑❑❑* ❑


Indicate Shade Here






SHADE

SHADE INSTRUCTIONS




� � � � � � �

� � � ��

� None

� Light

� Medium

� Dark


ENCLOSED WITH CASE



Other _____________________________



�

�

�

�

Full coverage




01-1125-0507


Date Sent: ___________________

Date Due: ___________________

Patient/ID: _______________________Lab: ______________________________________

Address: __________________________________

City: ______________________________________ State: _____ Zip: ___________


TOOTHNUMBER










PROVISIONALS

ZIRCONIA

ALL-CERAMICS

PORCELAIN TO METAL




IMPLANTS

Abutment: q Titanium q Zirconia q Other:__________

Specify system: q Nobel BioCare q Zimmer q 3i

q Astra q Dentsply q Straumann

q Other:__________ Specify diameter on Rx

PONTIC DESIGN

Rx

LABORATORY USE ONLY

By _____________ Mail ______________

FINAL CERAMIC SHADE PORCELAIN FUSED TO METAL ❑ Non-Precious* ❑ Noble ❑ WHN ❑ Captek YHN ❑OcclusalGold YHN

COMPOSITE RESTORATIONS ❑Composite ❑Fiber Reinforcement

PLAYSAFE MOUTHGUARDS❑ Jr ❑ Lt ❑ Lt Pro ❑ Med* ❑ Hvy ❑ Hvy Pro

❑ Helmet Strap Specify color(s) on Rx

❑Name ________________________________________________

VITALLIUM METAL PARTIALS❑Vitallium 2000* ❑Vitallium 2000 Plus ❑tcs/Vitallium ❑Valplast/Vitallium❑Titanium ❑Wironium ❑tcs/Wironium ❑ Lab select complete design❑Frame try-in ❑Frame w/occlus. rim ❑Frame w/setup try-in ❑Finish

CROWN & PARTIAL COMBINATION CASES

❑Future Partial: ___Vitallium ___Valplast ___tcs ___Attachments ❑ Fabricate RPD to fit restoration

MAJOR CONNECTOR

Maxillary Mandibular

❑Lab select ❑ Lab select

❑ _____________ ❑ ______________

Rest Areas Tooth #

❑Lab select ________________

❑ _____________ ________________


GL-421-1011

SNORING/SLEEP APNEA APPLIANCESUpper and lower models with protrusive bite required

❑ Silent Nite sl* ❑ TAP ❑ TAP 3 ❑ EMA

INCLUSIVE CUSTOM ABUTMENTS❑Titanium* ❑Zirconia w/ Ti-Insert ❑All-Zirconia

Specify implant system, brand and diameter on Rx IF NO OCCLUSAL CLEARANCE





FULL-CAST RESTORATIONS ❑ Noble-Cast 45 YN (40% Au) ❑ Non-Precious

❑ Noble-Cast 60YHN (57.5% Au)* ❑ White Noble

❑ Noble-Cast 67 YHN (64% Au) ❑ WHN (45% Au)

❑ OcclusalGold YHN (73.8% Au) ❑ Post & Core

❑ JRVT YHN (77% Au)

ZIRCONIA RESTORATIONS❑ BruxZir Solid Zirconia ❑ Prismatik CZ* ❑ Lava ❑ NobelProcera Zirconia

❑ ❑ ❑* ❑ ❑

Clasp Options Tooth#

❑Lab select _____________________

❑Metal _____________________

❑Estheticlasp _____________________

❑ Thermoflex _____________________

❑ _______________ _____________________

MARGIN AND METAL DESIGN

❑❑❑❑* ❑

DENTURES/FLEXIBLE PARTIALS❑ Flipper ❑ Denture ❑ Valplast ❑ tcs ❑ Dupe denture❑ Custom tray ❑ Occlusion rim ❑ Wax setup try-in ❑ Finish

❑Premium Brand Teeth (extra charge applies)

Shade ________ Brand _______________ Mould ________

❑Kenson Teeth (included at no extra charge)

Shade ______________ Mould _______________________

Acrylic shade: ❑ Ethnic: Lt ❑ Med ❑ Dk ❑Acrylic tabs available: G1 (standard) G2 G3 G4

❑ Name on appliance _________________________________________ (Additional charge)

Tooth setup ❑ Ideal ❑ Characterized ❑ Study model❑ Male ❑ Female Age ________

PROVISIONAL RESTORATIONS

❑BioTemps ❑Transition C&B ❑Smile Transitions

Abutment #s________________________________


❑Splinted* ❑Cement-on implant❑Individual units ❑Screw-retained implant


Amount of prep reduction: ❑1 mm* ❑2 mm


on tooth #(s) ____________ by __________mm


on tooth #(s) ____________ by __________mm *Standard unless specified otherwise

Indicate Shade Here

Signature _________________________________________________________ License # _____________________________(see reverse for limited warranty details)

❑ Check here to manufacture ceramics or full-cast using CAd/CAM

❑❑❑* ❑

NIGHTGUARDS/BITE SPLINTS ❑ Upper ❑ Lower

❑ Comfort H/S (hard/soft)* ❑ Comfort (hard) ❑ Semi-Hard EVA ❑ Soft EVA ❑ Astron CLEARsplint ❑ Processed Acrylic

ALL-CERAMIC RESTORATIONS ❑IPS e.max CAD* (Posterior) ❑IPS e.max veneer

❑IPS e.max Press* (Anterior)

❑Vivaneers No-Prep Veneers* ❑IPS Empress



Indicate Shade Here


GLIDEWELL LABORATORIES4141 MacArthur Blvd. • Newport Beach, CA 92660

800-854-7256 • Fax 800-599-9564 Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑ Photos ❑ Other: ___________________________

• UNIVERSAL Rx •

See Reverse for Working Times

Dr. Name _________________________________________________ Phone #__________________________

Acct. # ____________________________________ Patient Name ____________________________________

Address/E-mail _____________________________ Deliver by 5 p.m. on ____________________________

First Last

All Restorations Made in the USA

PONTIC DESIGN

Rx

LABORATORY USE ONLY

By _____________ Mail ______________





❑Name ________________________________________________




MAJOR CONNECTOR



❑ _____________ ❑ ______________

Rest Areas Tooth #

❑Lab select ________________

❑ _____________ ________________


GL-421-1011















❑ ❑ ❑* ❑ ❑


❑Lab select _____________________

❑Metal _____________________

❑Estheticlasp _____________________

❑ Thermoflex _____________________

❑ _______________ _____________________


❑❑❑❑* ❑





Shade ______________ Mould _______________________






Abutment #s________________________________






on tooth #(s) ____________ by __________mm



Indicate Shade Here



❑❑❑* ❑








Indicate Shade Here






Dr. Name _________________________________________________ Phone #__________________________



First Last


PONTIC DESIGN

Rx

LABORATORY USE ONLY

By _____________ Mail ______________





❑Name ________________________________________________




MAJOR CONNECTOR



❑ _____________ ❑ ______________

Rest Areas Tooth #

❑Lab select ________________

❑ _____________ ________________


GL-421-1011















❑ ❑ ❑* ❑ ❑


❑Lab select _____________________

❑Metal _____________________

❑Estheticlasp _____________________

❑ Thermoflex _____________________

❑ _______________ _____________________


❑❑❑❑* ❑





Shade ______________ Mould _______________________






Abutment #s________________________________






on tooth #(s) ____________ by __________mm



Indicate Shade Here



❑❑❑* ❑








Indicate Shade Here






Dr. Name _________________________________________________ Phone #__________________________



First Last


BITE SPLINTS / NIGHTGUARDSq Comfort H/S Bite Splint (Hard/Soft) q Comfort Bite Splint (Hard)

IF OCCLUSAL CLEARANCE IS LIMITED:q Call Doctor q Adjust Opposing q Make Metal Stop/Occlusion q Adjust Prep & Mark in Red q Make a reduction coping

P ____________________

PAD __________________

C ____________________

MS ___________________

ML ___________________

MO ___________________

FC ___________________

REDUCTION COPING____

IMPLANT ______________

CA CLASP _____________

CLASP ________________

R ____________________

S ____________________

POST F C S

PM ___________________

ATTACH M/F ___________

ERA ATTACH __________

ETCH _________________

WE ___________________

DT ___________________

E.max Stain ____________

E.max Layering _________

OVERNIGHT COURIER SERVICE

We honor VISA, MASTERCARD, DISCOVER CARD & AMEX.All cases returned via Overnight Courier Service

TERMS: All accounts are payable within 30 days of statement date. Accounts not paid within the stated terms will be sub-ject to C.O.D. status and a late charge of 2% of the unpaid balance. Prices subject to change without notice.

LIMITED WARRANTY/LIMITATION OF LIABILITY: Glidewell Laboratories (“the lab”) provides dental laboratory services(“devices”) in the belief that such devices will be useful but WITHOUT ANY WARRANTY—without even the implied warrantyof MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE—except that, subject to the return of devices that areplaced and then fail, the lab will, in its sole discretion, either repair or replace such devices without charge for the lab’s costof materials and workmanship or refund the original price paid, for a period of ninety (90) days from the date of delivery (here-after referred to as the lab’s “remake warranty”). The remake warranty does not cover breakage resulting from accident ormisuse. The lab’s remake warranty is the lab’s sole obligation and the client’s sole remedy: you agree to pay all other costs,such as but not limited to the cost of preparation or veneering. Except where prohibited by law, THE LAB WILL NOT BELIABLE FOR ANY LOSS OR DAMAGES ARISING FROM THE USE OF DEVICES, WHETHER DIRECT, INDIRECT, SPECIAL,INCIDENTAL OR CONSEQUENTIAL, regardless of the theory asserted, including warranty, contract, negligence or strict lia-bility. You agree to indemnify and hold the lab harmless from and against any claim or demand, including reasonable attor-neys fees, made by any third party due to or arising our of your use of said devices. The lab does not guarantee the perform-ance of independent carriers. You acknowledge that limitations on liability are a usual part of business-to-business relation-ships, and a common practice in the dental industry, and that such limitations as specifically stated above are relied upon bythe lab when establishing the cost of providing dental laboratory services to your order. All matters arising from said relation-ship shall be interpreted and enforced in accordance with the laws of California.

IN-LAB WORKING TIMES

CopingsPFM/Captek/Lava/Wol-Ceram/Cercon/Prismatik CZ ......................... 3 daysProcera Copings ..................................................................................... 7 daysProcera Custom Implant Abutment ....................................................... 8 days

Unfinished CrownsPFM/Captek/Lava/Wol-Ceram/Cercon/IPS Empress/IPS e.max/CZ .. 4 days

Finished CrownsPFM/Captek/Lava/Wol-Ceram/Cercon/IPS Empress/IPS e.max/CZ .. 5 daysBioTemps Provisionals with wire or fiber reinforcement ..................... 5 days

with cast metal substructure................................................................... 6 daysextra cost for rush service........................................................... 1, 2 or 3 days

Transition Crowns & Bridges ................................................................. 6 days

Please allow for the full working time on each type of product. Working times do not includeWeekends or Holidays. BioTemps Rush Services available (see box below).

All BioTemps rush cases must be pre-scheduledby calling Customer Service before the case is shipped.Time of pick-up and delivery may affect turnaround time.

FOR LAB USE ONLYTELEPHONE CALL RECORD

LAB ACCT#

PATIENT/ID

RE

RESULT

DATE DUE IN LAB

DATE OF CALL INITIAL

To pre-schedule your BioTemps rush case, call: 800-787-4736

Hogan Dental Lab offers the following:

Margins not defined: _____________%

___ Pull marks: M____D____L____B____

___ Tissue over margins: M____D____L____B____

___ Build up: M____D____L____B____

___ Bubble: M____D____L____B____

IMPRESSION

___ Cut the impression to create bite registration.

___ Used the impression to set the bite.

___ Hand articulation based on wear marks.

___ Light & heavy body not intact at prep

PFM (base, noble and high noble alloys)IPS e.max® BRUXZIR®

ZIRCONIAVENEERSIMPLANTSBITE SPLINTS/NIGHTGUARDS

HOGAN DENTAL LABORATORYTERMS AND POLICIES

WARRANTY: Hogan Dental Laboratory (HDL) guarantees its work for one year against defects in materials and craftsmanship. Please note: Bite Splits/Nightguards carry a 6 month warranty.REMAKES: All remakes will be at no charge except under the following circumstances: Dentist did not resubmit all original goods including impressions, models and restorations. HDL must have these goods to assess possible restoration or repair cost to dentist and to determine if original product is repairable or necessitates remanufacture. HDL inquired about the die, margin or impression. However, the dentist approved and requested the completion of the case. HDL requested for a framework try-in, but the dentist declined and asked for a completed case. The teeth are re-prepared.TERMS: Prices subject to change without notice. All accounts are payable within 30 days of statement date. Accounts not paid within the stated terms will be subject to COD status and a late charge of 2 percent of the unpaid balance. All costs for collection on any account will be the responsibility of the debtor.

laboratories glidewell - …hogandentallab.com.r16.millsys.org/wp-content/uploads/2015/04... ·...

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