Orthodent RX Form-2

	311 Viola Street., Oshawa, ON L1H 3A7 Tel: (905) 436-3133 Toronto Line: (905) 427-2872 Toll free: (800) 267-8463 Fax: (905) 723-2331 info@orthodent.ca

Rx Form

Dr.

Email

Phone

Order Date

Patient Name

Patient Age

Delivery Date

Delivery Time

Delivery Address

Upper Teeth

Lower Teeth

Instruction

Office Use Only

Rec'd

Packed

Prep

Q/C

Please Specify

Precious‎ Semi-Precious‎ Non-Precious‎

Centric Contact

Foil Relief‎ Positive Contact‎ Cusp Fossa‎

Lateral Excursion

Cuspid Guidance‎ Group Function‎

Margin Adaptation

Exactly to Finish Line‎ Slight Overextension‎

Labial Margin

Fine Gold Collar‎ Porcelain Butt Margin‎ Porcelain To Margin‎

Pontic Design

Harmony

Cone

Hygenic

Ridgelap

Contact (Embrassures)

Board

Normal

Point

Special Shade Selection

Electronic signature

Clear