LAB ORDER FORM
Doctor Name
Date
Organization
PATIENT DETAIL:
Name
Sex
Female
Male
Age
CASE DESCRIPTION
Order Date
Return Date
Teeth
11
12
13
14
15
16
17
18
Teeth
21
22
23
24
25
26
27
28
Teeth
41
42
43
44
45
46
47
48
Teeth
31
32
33
34
35
36
37
38
51
52
53
54
55
61
62
63
64
65
71
72
73
74
75
81
82
83
84
85
FIXED PROSTHESES
Type
Zirconia
All Ceramic
Porcelain Fused To Metal
Direct Metal Laser Sintering
Full Metal
Additional Gingival Ceramic
Others
Please specify
TOOTH SHADE
IMPLANT PROSTHESES
Implant Brand
Platform Size
Type
Screw Retained Prosthesis
Cement Retained Prosthesis
Screw Cement Retained Prosthesis
Customized Crown/Abutment
Implant Hybrid Denture
Implant Bar Overdenture
Implant Malo Prostheses
Surgical Guide
Others
Please specify
REMOVABLE PROSTHESES
Acrylic Partial(RPD)
Cast Partial
Complete Denture
Over Denture
Immediate Denture
Valplast
Others
MAXILLOFACIAL PROSTHESES
Surgical Obturator
Definitive Obturator
Mandibular Anterior Positioning Device
Others
Please Specify
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