ACADEMYDENTAL LABORATORY INC.

2220 EAST 117TH STREET DATE SENT:

ENVELOPES R FORMS STICKERS

C H A R A C T E R I Z AT I O N
BOXES

BURNSVILLE, MINNESOTA 55337

(952) 894-8311
RETURN DATE:

DATE SENT TRACERS:

RX
SHADE TYPE OF TEETH
PATIENTS NAME TRAY: As shade guides often vary. Send your shade tab if possible.

ADDRESS ARTICULATOR:
R

CITY & STATE SHADE GUIDE:

DOCTOR ACCOUNT #:
GROUP HEALTH PLAN (DENTAL)

MON. TUES. WED. THUR. FRI. SAT.

TRIAL FINISH

❏ MALE ❏ FEMALE
❏ VIGOROUS ❏ DELICATE ❏ SOFT
SHADE AGE

FULL UPPER FACIAL CHARACTERISTICS

CHECK BASIC FACE FORM
FULL LOWER ❏ SQUARE ❏ SQUARE TAPERING ❏ TAPERING ❏ OVOID
CHECK FACIAL ASYMMETRY
PARTIAL UPPER ❏ DOMINANT RIGHT SIDE ❏ DOMINANT LEFT SIDE
(GIVE NAME OF MANUFACTURER FOR MATERIALS AND TEETH)
PARTIAL LOWER
TEETH: ANTERIOR: PORCELAIN PLASTIC
IMMEDIATE UPPER
SHADE AND MOLDS

IMMEDIATE LOWER POSTERIOR: PORCELAIN PLASTIC

8 9 DESIGN CASE 24 25
7 10 23 26
BITE BLOCKS SHADE AND MOLDS 22 27
6 11
MATERIALS PARTIALS 21 28
STABILIZED 5 12
TISSUE BLEND UPPER 20 29
4 13
JUMP OR DUPLICATE REGULAR UPPER 19 LOWER 30
LUCITONE LOWER 3 14
CHARACTERIZED
CAST FRAME 18 31
RELINE LUCITONE 2 15
HI-IMPACT GOLD RIGHT LEFT LEFT RIGHT
REPAIR
ETHNIC LIGHT WROUGHT
POST DAM
ETHNIC MEDIUM TEMPORARY
RELIEF ETHNIC DARK Signature D.D.S License No.