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SAMZ Dental Lab

Prescription

+92 300 8005219
mubasher@samzdentallab.com
Practice
Account number
Dentist
GDC number
Patient reference
Date
Stage required

Restoration or appliance

CrownBridgeVeneerInlay / onlayImplant crownFull denturePartial dentureAppliance

Material

ZirconiaIPS e.maxPFMFull castCompositeAcrylicCobalt-chromeFlexible

Tier

BasicAdvance
Tooth or teeth (FDI or Palmer notation)
Shade
Stump shade
Implant system, platform and diameter (implant cases)

Enclosed

Upper impressionLower impressionBite registrationOpposing modelScan sent as STLImplant componentsPhotographs

Instructions

Dentist's signature
Date

By submitting this prescription you accept the SAMZ Dental Lab terms and warranty, published at samzdentallab.com/terms. Do not write the patient's name on this form; use a reference.