Removable Prosthetic Rx DENTURES

Laboratory Procedure Prescription □ Upper □ Set-up/Try-in* □ Finish

□ Lower □ Elite™ Denture* □ Cast metal mesh
REQUIRED INFORMATION □ Both □ Premier™ Denture □ Wire
□ Custom tray reinforcement
(extra charge)
Doctor Name _______________________________________________________ □ Immediate/Surgical □ Patient ID
Last First
□ Base plate Denture (extra charge)

Practice Name_______________________________________________________ □ Bite rim

PARTIALS
Address_____________________________________________________________

Phone_______________________________________________________________
□ Upper □ Lower □ Both □ Set-up/Try-in* □ Finish
Patient Name________________________________________________________
□ Custom Tray □ Base Plate □ Bite Rim
Base Material (non-metal) Tooth Type
Patient Chart #______________ □ M □ F DOB______________________
□ Acrylic Partial* □ Elite™* □ Premier™
Rx Date___________________ Due Date/Delivery on___________________ □ CustomFlex™ Partial (extra charge)

(standard working time if no date given)

□ Valplast® Partial Design
Case turnaround times are based on the date the Rx is received at DDS Lab. Please allow
10 business days (M-F) from that date and 13 business days for complex cases. □ Immediate/Surgical partial □ Horseshoe palate (upper)
□ Full palatal metal
□ Teeth to be extracted from model now Metal Framework coverage (upper)

□ Teeth removed from model at final processing □ Chrome Cobalt* □ A-P strap
□ Vitallium □ Lingual bar (lower)
□ Lingual apron (lower)
EXTRACTIONS □ Elite Metal Partial* □ Wrought wire clasps (2*)
Please MARK all teeth to be extracted and replaced
□ CustomFlex™ Partial □ Ball clasps
□ Valplast Partial □ Cosmetic clasp
7
8 9
10 32 17 □ Cast metal only □ Unilateral (nesbit)
5
6 11
12 31 18 □ Cast metal w/ Set-up/Try-in
4
Upper Arch
13 30
Lower Arch
19 □ Cast metal w/ Bite rim
3 14 29 20
2 15 28 21 NIGHTGUARDS/SPLINTS OTHER
27 22
1 16
26 25 24 23 □ Upper* □ Lower □ Upper □ Lower
□ Soft □ Reline □ Rebase
CASE DESIGN
□ Hard (clear acrylic) □ Repair
□ Follow the doctor’s design □ Best design for fit and function □ FlexiGuard™ (hard-soft)*
□ Astron thermoguard □ Soft liner
7
8 9
10 32 17 □ Sports guard Level____ □ Add clasp_________________
(CLASP TYPE)
6 11
5 12 31 18 □ dreamTAP® snore guard
4
Upper Arch
13 30
Lower Arch
19 □ Deprogrammer mini
3 14 29 20 □ Deprogrammer full
2 15 28
27 22
21
□ No opposing
1 16
26 25 24 23
Acrylic Shade (REQUIRED)
RX SPECIFIC INSTRUCTIONS

□ Lucitone 199* □ Light Meharry

□ Light Pink (Luc 199L) □ Meharry (Luc 199D)
Tooth shade_________________ Tooth Mould No._____________________
(REQUIRED)
Shade Guide Used___________________________________ (Vita is default)
Please provide any photos, study models, diagnostic casts with case
Email photos to: ddslabpix@ddslab.com
**The person signing this form is an authorized signer and, along with the dental practice, accepts
responsibility for payment of all related charges, as well as any legal costs, collection and other fees incurred
by DDS Lab in the event the account is sent to collections or litigation.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

*Standard design if an option is not selected Dentist signature**__________________________________________________

(REQUIRED)
5440 Beaumont Center Blvd, Suite 400 Dentist license no.__________________________________________________
Tampa, FL 33634 | (877) 337-7800 (REQUIRED)
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