DOCTOR'S PREFERENCE CHART.Instructions:
Please fill in the information fields. Once you have completed this page,
CLICK the "Submit Form" icon to send your preferences. If you need to
change the form or start over, simply CLICK the "Reset" icon.
Name:
DDS:
DMD:
Practice Name:
Street Address:
City:
State:
Zip Code:
Phone:
Email:
CROWN AND BRIDGE
Metal Collars:
Anteriors:
Yes No
Posteriors:
Yes No
Metal Occlusals:
Yes No
When Needed
May we relieve the opposing tooth?
Yes No
If model looks distorted, may we call you?
Yes No
Contacts:
Point
Normal
Broad
Oval
Heavy
Indicated on prescription
Preferred Alloy:
Predominantly Base
Noble
High Noble
Staining:
None
Natural
Heavy Characterization
Indicated on prescription
Occlusal Clearance:
In Occlusion
Out of Occlusion
Foil Relief
DENTURES
Trays:
Solid:
Perforated
Bite Blocks:
Stabilized Base
Wax Base
Tooth Selection:
Hardened Acrylic
Composite Resin Reinforced
Occlusals on Posterior Teeth:
Zero Degrees
Twenty Degrees
Thirty Degrees
Lingualized
Functional
Indicated on prescription
Set-up:
Ideal
Aesthetic
Palatal Relief:
Yes
No
Palate:
Smooth
Anatomical
Carved Labial Buccal:
Yes
No
Stippled:
Yes
No
Polish Peripherals:
Yes
No
Full Roll:
Yes
No
Finish Base Material:
Lucitone 199
Indicated on prescription
CAST PARTIALS
Preferred Clasp Design:
1.
2.
3.
Can We Change Design If Necessary?
Yes
No
Should We Call You About Any Design Changes That Would Improve
Aesthetics or Retention?
Yes
No
Type of Major Connector:
Upper
Lower
Framework Try-in:
Yes
No
Framework with Set-up Try-in:
Yes
No
Indicated on prescription
Type of Teeth on Framework:
Plastic
Porcelain {when possible}
Finish Base Material:
Lucitone 199
Characterized Lucitone
Plain Lucitone
Indicated on prescription
Other Comments or Instructions:
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