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 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 Send