7186 South Highland Drive, Suite 150
Salt Lake City, Utah 84121
(801) 733-9700
fax (801) 733-9970
www.ecodentlab.com
Toll-Free (866) 541-9700
L A B O R ATO R I E S
quality dental prosthetics and more
1. Date Due
6. Tooth Shade & Characteristics
Overall shade:_______________ Cervical shade:_ _____________
2. Work Authorization
Middle shade:_______________
_____________________________________
Doctor
NOTE: Due date is one day before
patient’s next appointment
Incisal shade:_______________ _____________________________________
Stump shade:_ ______________
Mandatory for Empress
Address
OUR FIRST CROWN
Age _____
_____________________________________
Male
Female
State
Zip
Phone
Texture:
Smooth
_____________________________________
Full
porcelain
no metal
showing
Lingual
collar
____mm
LVI
Required Data
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
None
Rough
Standard
Patient Name
3. Tooth Number(s)
Medium
Metal
occlusal
excluding
buccal cusp
Hypo-Calcification
Occlusal Stain
Metal
occlusal
including
buccal cusp
Lingual
collar
____mm
None
Standard
Standard
Light
Light
Medium
Medium
Dark3/4
metal
lingual
Full
metal
lingual
Heavy
Midline Shift R ________ mm L ________ mm
Length of Centrals ________ mm (from Cervical margin)
LVI Smile Catalog selection ______________________________________
7. Tooth Translucency
4. Restoration Type
PFM (Base Metal)
PFM (Semi-Precious)
PFM (High Noble Yellow Gold)
PFM (High Noble White Gold)
IPS e.max® Empress®
IPS e.max® Empress®
IPS e.max® Empress®
IPS e.max® ErisTM
Full Gold Crown (54%)
Full Gold Crown (74%)
CERCON TM
(Crown)
(veneer)
1
(inlay / onlay)
2
CAPTEK™
5
6
7
8
9
Enter number of
Metal
Metal
tooth
occlusal translucency
occlusal
excluding
including
buccal cusp
buccal
cusp
type
in box to
left.
9. Insufficient Room
In Occlusion Standard
Out of Occlusion
Foil Relief
Reduce and Mark
Please Call
Reduction Coping
10. Special Instructions
Authentic (Ceramic)
Authentic (PFM)
4
Lingual
collar
____mm
8. Occlusal Clearance
PROCERA™
Wolceram™
3
Full
porcelain
no metal
showing
Implant ___________________
BIO 2000™
Specify Type
Intrinsic Tooth #(s) _______________
Intrinsic Design, exclusively offered by Ecodent Laboratories, is internally
and externally stained and layered for optimal esthetic results
Have you included the following?
Impressions
Bite
Opposing
5. Case Design (Study model required for anterior cases)
A
Standard
Metal
Design
B
Margin / Pontic
Design
Full
porcelain
no metal
showing
Lingual
collar
____mm
Porcelain Labial Butt Margin
Metal Margin ____mm
3600 Porcelain Margin
Full
porcelain
no metal
Metal
showingocclusal
excluding
buccal cusp
Lingual
Metal
collar
occlusal
____mm Metal
excluding Lingual
buccal cusp
occlusal
collar
including
____mm
buccal cusp
Standard
Metal
occlusal
including
3/4
buccalmetal
cusp
lingual
Lingual
collar
____mm
Full
metal
lingual
3/4
metal
lingual
Please Send:
Full
Rx’s
Airbills
metal
lingual
Shade
Pre-Op Model
Photos
Boxes
Call me before proceeding with case
Please evaluate my preps and impressions
Doctor’s Signature ________________________________________________
Todays Date _________________
Lic. # ______________________
Lingual
collar
____mm