Dr. Signature:________________________ DDS License# ______________Signature is acceptant of sole responsibility for payment and agrees to pay all legal costs in the event of a suit, including reasonable attorney fees. San Diego Dental Design. requires that each case be accompanied by a lab slip - this is considered a binding work order and is subject to all stated terms and conditions.

Patient Name: ____________________________________________ Age: _______ Preparation Date: ____ /____ / ____ Delivery Date: ____ / ____ / ________________

Dr. Name: _____________________________ Dr. Phone: ______________________

Address: _______________________ City: _________________ Zip Code: ________

Pontic DesignCrown Design

All PFM

NP Tilite AlloySP Semi-preciosHN WhiteHN YellowCaptek

Call for a pickup: (760) 855-709112285 World Trade Dr. Ste G San Diego CA, 92128

San DiegoDental Design

All Zirconia

BruxZirLava HT ZirconiaLayered ZirconiaInlay / OnlayInlay / Onlay

Implant CrownCeramic

PFMCaptek

Zirconia

Screw Retain Pink Gingival Porcelain

Zirconia AbutmentTitanium Abutment

Hybrid AbutmentHader Bar

Abutment & Bar

Placemat Jig

Follow Tissue Contour

RX Number

ProductsCDTConcorde Dental Technician

Lab

Solid CrownLayered CrownFramework Try-in

Shade#

Porcelain MarginBuccal Margin

Metal Margin360 MarginLight

MediumHeavy

ContactLightMediumHeavy

Occl Contact

Please make sure that the due date is 1-2 days before Pt’s appointment dete.

Cement Retain

Surgical Guide

XP

All Ceramic

e.max Crowne.max Veneere.max layeredCeramic Post

please print legibly so we can understand your case better.

XP

Dental DesignImplant Technology

Zimmer • Straumann • Astra Tech • Bio Horizons • Mega’Gen • Biomet 3i • Nobel Biocare