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ESTHETIC ALLIANCE

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9061 W. Post Rd. Las Vegas, NV 89148
phone 702.363.4877 fax 702.433.4806
DateDue Date
Doctor Phone Number
Address
Name of Patient Gender Age
Items Included with Case
Master Impression Diagnostic wax-up Face bow transfer jig
Opposing impression or model Model or impression of provisionals Other
Stick Bite Pre-operative models
Bite registration Photos(Qty.) Slides(Qty.)
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
Goal of Final Case
Type of Restoration Desired
Empress Esthetic - teeth #s Pressed over Zirconia - teeth #s
Emax - Lithium Disilicate - teeth #s Other - teeth #s
Emax - Pressed over Zirconia - teeth #s
Vertical DimensionOpen Bite
Vertical measurementmm CEJ # to CEJ tooth #
Length
Centrals (tooth#))mm less than centrals Canine (tooth #)mm
Any Special instructioins
Shape
Smile guide design # Match photographs included
Smile catalog design Match contralateral
Other
Shade of Preparation
Stump shade teeth #s ST Stump shade teeth #s ST
Stump shade teeth #s ST Stump shade teeth #s ST
Shade
Body Shade Gingival Incisal Occlusal Staining
Incisal Translucency
Minimal (0.5mm) Moderate (1.0mm) Maximum (1.5mm)
Shade of Incisal Translucency
Clear Smoke Frosted Amber
Surface Texture
High Medium Light Smooth (not surface texture)
Surface Finish
High Glaze Polished Gloss Satin Finish Low Glass
Provide reduction coping if necessary to improve aesthetics, reduce opposing or call and ask to re-prep
Miscellaneous Information
Doctor's SignatureLicense #
A Charge of 1.75% per month (21% APR) will be applied to all past due accounts. In event of collection action, deblor agrees to pay all collections cost, including attorney fees.