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Patient's Age
Dental Script
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Patients's Name
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Does your patient have any special considerations?
Address
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Doctor's Name
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Best Contact Number
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Material
CAD-CAM
Alloy
E max
PFM
Zirconia
Gold Crown
Occlusal Contacts
None
Light
Normal
Heavy
DATE REQUIRED
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Type of Restoration
Crown
Bridge
Denture/Partial
Bite plane (upper or lower)
Essix retainer (upper or lower)
Custom tray
RETURN APPOINTMENT DATE , if known
*
Sex
Male
Female
Appointment Type
Try-in
Finish
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