Submit Order Please enable JavaScript in your browser to complete this form.Select *New CaseContinuation/Remake TYPE Patient File Clinician *DateClinic NamePatient NameDue DateClinician AddressRESTORATION TYPECrownBridgeInlay/OverlayBonded Bridge/ WingVeneerDiagonostic Wax-up (Advise Teeth No.)PMMA (Temporary Crown)Post & CorePFMImplant Crown *Custom tibase and crown*Custom tibase and crown layered*Note: Price subject to changeCeramic *e.max**UZir – Ultra Translucent Zirconia**FMZir – Fully Monolithic ZirconiaPFZ – Porcelain-Fused-to-Zirconia**Note: Price subject to changeSurgical guides: *Single implant guideMultiple implant guidesFull arch guidePilot guide onlyTOOTH CHARTSelect *UpperLowerStump shadeNote: Provide stump shade if non-vital Email images: bespokesmilelab@gmail.comEMBRASUREOpenClosedOCCLUSAL CONTACTHeavyLightOpenPROXIMAL CONTACTNormalExtendedPONTIC CONTACTDefaultScans Sent Via *DS CoreWeb Portal UploadAnteriorPosteriorFile Upload Drag & Drop Files, Choose Files to Upload You can upload up to 6 files. ADDITIONAL INSTRUCTIONSSubmit
