Warranty Card

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+7890008331
info.urstoothfully@gmail.com
643B, New Alipore Road, Block O, New Alipore, Kolkata, West Bengal 700053

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Clinic Academy

Online Lab Order

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+7890008331
info.urstoothfully@gmail.com
643B, New Alipore Road, Block O, New Alipore, Kolkata, West Bengal 700053

Home
About
Product
Contact

Online Lab Order

Doctor Name

Limited Warranty Card

LAB ORDER FORM

Doctor Name

Date

Organization

Patient Detail:

Sex

Female Male

Name

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