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    The document contains information for a dental lab order form, including the name and contact information of Derral Bush, C.D.T. and their dental lab. The form requests information about the patient, tooth shade, type of crown material, and date of appointment. It also includes spaces for the dentist's signature and payment information.

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    The document contains information for a dental lab order form, including the name and contact information of Derral Bush, C.D.T. and their dental lab. The form requests information about the patient, tooth shade, type of crown material, and date of appointment. It also includes spaces for the dentist's signature and payment information.

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    The document contains information for a dental lab order form, including the name and contact information of Derral Bush, C.D.T. and their dental lab. The form requests information about the patient, tooth shade, type of crown material, and date of appointment. It also includes spaces for the dentist's signature and payment information.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    21 views1 page

    RX GREEN

    Uploaded by

    matt3245
    The document contains information for a dental lab order form, including the name and contact information of Derral Bush, C.D.T. and their dental lab. The form requests information about the patient, tooth shade, type of crown material, and date of appointment. It also includes spaces for the dentist's signature and payment information.

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    Derral Bush, C.D.T. Derral Bush, C.D.T.

    TSBDE permit #1706 TSBDE permit #1706

    Office: 972.412.1701 Cell: 214.794.3765 Office: 972.412.1701 Cell: 214.794.3765

    Web site: bushdentallab.tumblr.com Web site: bushdentallab.tumblr.com


    Email: bushdentallab@verizon.net Email: bushdentallab@verizon.net
    Practice_________________________________________________________________________ Practice_________________________________________________________________________

    Patient_______________________________________________Age_________Gender_________ Patient_______________________________________________Age_________Gender_________

    Date_________________________________Return Date_________________________________ Date_________________________________Return Date_________________________________

    Appointment Time for Custom Stain___________________________________________________ Appointment Time for Custom Stain___________________________________________________

    FCC PVC NP Noble High Noble {All Ceramics e.max Lava Generic Zirconia} FCC PVC NP Noble High Noble {All Ceramics e.max Lava Generic Zirconia}
    Porcelain Margin 360o Porcelain Margin Metal Margin on Facial Porcelain Margin 360o Porcelain Margin Metal Margin on Facial

    Tooth Shade _________________________Stump Shade For All Ceramic Crown _________________________ Tooth Shade _________________________Stump Shade For All Ceramic Crown _________________________

    1 2 3 4 5 6 7 8 | 9 10 11 12 13 14 15 16 1 2 3 4 5 6 7 8 | 9 10 11 12 13 14 15 16

    32 31 30 29 28 27 26 25 | 24 23 22 21 20 19 18 17 32 31 30 29 28 27 26 25 | 24 23 22 21 20 19 18 17

    Dr. Signature: ______________________________________________ License No. _______________________ Dr. Signature: ______________________________________________ License No. _______________________

    American Express Visa Master Card Accepted American Express Visa Master Card Accepted

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