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ProSmile Lab Form

Doctor/Practice Name *

Patient Name *

Email Address *

License #

Date

Case Due Date by 5PM

RX Instructions

Finished Shade

Prep Stump Color

Instructions

Fixed Restorations

Full Contour (monolithic)PFZ (layered)

Full Contour (monolithic)Layered

PFM (layered) - non preciousSemi-PreciousHigh Noble WhiteHigh Noble Yellow

Implant

Custom AbutmentStock Abutment

Cement RetainedScrew Retained

Full Contour Zirconia (monolithic)Semi Precious (monolithic)PFZ (layered)PFM (layered)

Removable

StandardImmediate

Comfort (Hard/Soft)Thermo-GuardNightguard

Standard Cast PartialCast Partial - Frame OnlyFlexible PartialAcrylic Partial

Full Arch Bundle: Provisional + Zirconia FinalSmile DesignChair-side Conversion

Teeth Selection

Based on the image below, please select applicable teeth for this case:

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Case Photos

Drag and Drop (or) Choose Files

Consent *

Signature *

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