Donaghey Dental Lab Prescription Form

Dr. Name

First NameLast NameSuffix
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
License Number
Delivery Date

MonthDayYear
Date
Restoration Type

Full Contour ZirconiaHT+ (High Translucent Zirconia)PFZ (Porcelain Fused to Zirconia)Emax CADFull Cast-NobleFull Cast-High NobleDiagnostic Wax-up
Special Instructions
*Indicates Default Preferences
Contacts

NormalBroad*Pinpoint
Occlusion

In Occlusion (0.0mm)Light Occlusion (0.15mm)Out of Occlusion (0.3mm)*
Limited Clearance

Call Doctor*Relieve OpposingRelieve Prep.Make Reduction Coping
Pontic Design

BulletRidge LapHygienicModified Ridge Lap*
Tooth Number Upper (Select all that apply)

12345678910111213141516
Tooth Number Lower (Select all that apply)

1718192021222324252627282930213233
Shade
Implant Restoration

Screw RetainedCustom Titanium AbutmentCustom Zirconia Abutment
Implant System
Diameter/Platform
Choose Shipping

Fed ExUPSPick Up *within 30 mile on Conway
Have any photos or .stl files to add to this prescription?

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By signing below I understand that this online form takes the place of a written prescription. By signing and clicking submit I also understand that the order for this prescription has been placed and I will be billed for the finished product. All information on this form is final and correct.
Doctor Signature

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