AvaDent Digital Denture Prescription ® For Implant-Retained Denture Packages DOCTOR INFORMATION Last Name: License #: First Name: Email: Phone #: Website: Fax #: BILLING ADDRESS: SHIPPING ADDRESS: Address 1: Address 1: Address 2: Address 2: City: City: Zip/Postal Code : State: Same as Shipping Address Zip/Postal Code : State: Country: Country: PATIENT INFORMATION Last Name: First Name: AESTHETIC MEASUREMENTS Tooth Width Tooth Height TOOTH SPECIFICATIONS Bite Plane* (if applicable) Tooth Shape (Optional) Small 1 Medium 2 Large 3 Triangular N/A N/A Ovoid ACRYLIC BASE AvaDent® Light AvaDent® Original AvaDent® Dark Lucitone® 199 Dark Pink Age: VITA Tooth Shade Square A1 A2 A3.5 B1 OM3 C1 Sex: Male Female Fully-Milled Teeth1 Mould #1 Occlusion Anatomical Lingualized Flat on Flat Anterior Posterior PHOTO COMMUNICATIONS Please supply close-up photos of smile, lips at rest and biteplane. (profile & front views) Photos included Photos emailed to: [email protected] RESET NEXT PAGE 1 All teeth are fully-milled, mould types are similar to Dentsply Portrait IPN. ©2014 Global Dental Science, LLC. AvaDent® is a registered trademark of Global Dental Science, LLC. Lucitone® is NOT a registered trademark of Global Dental Science. FD_Prescription_v.29 art1 AvaDent Digital Denture Prescription ® For Implant-Retained Denture Packages IMPLANT INFORMATION # of Implants: Implant Type: Brand: Fixed-Detachable FIXED-DETACHABLE INFORMATION Bar Type: Wrap-Around OVER-DENTURE INFO No Tissue Clearance: Montreal Yes _______mm 1 - Guided Surgery Package 2 - Freehand Surgery Package 3 - Freehand Surgery Package w/Hybrid Try-In 4 - Final Fully Milled Hybrid Prosthesis 5 - Re-Tread of Existing Final Hybrid Prosthesis 6 - Minimal Surgery Package ü = Included in Package U-Dolder Hader Arches: Upper Lower APD = AvaDent Provisional Denture ASG = AvaDent Scanning Guide NSG = Nobel Scanning Guide Bar Type: Package Contents: Fixed-Detachable Package Selection: KEY: Removable Over-Denture APD ASG NSG ABRG ü ü ü X X ü ü ü X X X X X X ü -Upper -Lower -Upper -Lower X X X ABRG = AvaDent Bone Reduction Guide AOLS = AvaDent Occlusal Locking Splint ACD = AvaDent Conversion Denture = Optional Item (CAN be added to package) ü X X X AOLS ACD AVJ AIRD ü ü X X X X ü X X X ü X X X X X AHTI -Upper -Lower -Upper -Lower -Upper -Lower X X X X ü ü X X Locator AHP ü ü ü ü ü ü O-Ball ERA FINAL CHECKLIST Disinfected Records Completed Prescription Patient Photos (included or emailed) AIRD = AvaDent Implant Record Device AHTI = AvaDent Hybrid Try-In AHP = AvaDent Hybrid Prosthesis X = NOT Included in Package (CANNOT be added to package) ORDER INFORMATION Today’s Date: Notes: Due Date:1 Global Dental Science, LLC 15730 N 83rd Way Scottsdale, AZ 85260 p 855-282-3368 • f 480-471-8763 [email protected] www.avadent.com Digital Preview: Provide me with a Digital Preview for approval. (NOTE: Case will proceed only upon receipt of your approval.) Signature: PRINT 1 Due Date must be at least 14 calendar days after your shipping date. Digital Preview delays or prescription problems may result in longer processing time. Schedule patient’s next visit accordingly. ©2014 Global Dental Science, LLC. AvaDent® is a registered trademark of Global Dental Science, LLC. Lucitone® is NOT a registered trademark of Global Dental Science. RESET SUBMIT PREVIOUS PAGE FD_Prescription_v.29 art1
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