WE ACCEPT DIGITAL IMPRESSIONS Dr. Name ______for design and/or complete fabrication. Send STL files to Date Prepped ______Dental Lab [email protected] Date Needed Back ______Time ______209 W. Central Avenue • Lompoc, CA 93436 Call us or visit our website (resource page) Patient Name ______805.735.7888 • 800.585.3111 • FAX: 805.735.2388 for more information. Email: [email protected] robertsondentallab.com Patient Info: M ___ F ___ Age _____ www.robertsondentallab.com Tooth Number ______MATERIAL DESIGN METAL DESIGN Zirconia Occlusion o Coping With Full Porcelain Coverage : o o Monolithic MPa 1200 0.00 mm o Metal Coping With Porcelain Coverage* o Aesthetic-Ultra MPa 575 o 0.25 mm out* o Aesthetic-Super MPa 748 o 0.50 mm out o Coping 360° Collar 0.5mm o Layered o 1.00 mm out o Metal Occlusal Excluding Buccal Cusp o Zirconia Occlusal/Lingual Buccal Margin Design o Metal Occlusal Including Buccal Cusp Lithium Disilicate o Supported Margin o Metal Lingual o Call me to discuss case o Monolithic o Crown o Porcelain Butt Margin o o Dr. Signature ______Layered Veneer If No Occlusal Pontic Design Occlusal Staining Clearance o o o o o None Lic. # ______o PFM (select metal below) o Call Dr. o Light* o FullCast (all metal units) o Spot Prep o Medium IMPLANTS o Non-precious o Spot Opposing o Heavy Brand / System ______o Noble (semi-precious)* o Metal Occlusal Size ______o High Noble White (precious) Make This My Preference o Cement retained o Screw retained/ Hybrid o High Noble Yellow (precious) o Yes o No o Stump: Shade: Finish: Try-in: Mould: Implant Temp o Metal Try-in o Diagnostic Waxup o Temporaries Abutment Material Type

o Titanium abutment o Zirconia abutment Removable Prosthodontics o Anodize metal abutment Preferred Tooth: o GENISYS Digital Denture Alameter Measurement ______o Economy o Add AED PLEASE SEND MORE o Mid o Denture Papillameter Measurement ______o RX’s o Lab Boxes o Shipping Labels o Premium o Immediate Denture o Bite Rims PLEASE INDICATE Partial Denture: o Surgical Guide Photos o Metal Frame o Custom Tray Tooth Map Upper Tooth Map Lower o Memory Card / Thumb Drive / CD Enclosed o Duraflex o Mouthguard o o 8 9 Prints Enclosed Zirlux Acetal o Tap III 7 10 o 32 17 o E-mailed to [email protected] Stayplate/Flipper o Repair/Reline/Rebase 6 11 o 31 18 Wire Clasp o Other - Specify in Rx 5 12 Please check All that Apply o Space Maintainer 4 13 o Bleaching Tray 30 19 o o Pre-Prep Model Included o Opposing Model Valplast o Antiseptic Tray 3 14 o Snap-On Smile 29 20 o Case Has Been Disinfected o Doctor to Trim Die o To Completion 2 15 28 21 o Bite Registration Enclosed o Study Models Night Guards: 1 16 27 22 o Thermo Form o Processed o Key Soft 26 25 24 23 Please include a study model on all work involving anterior teeth. o Hard o Hard/Soft o Hard Only Terms: Net 30 with a service charge of 2% per month on charges over 30 days after statement date. Only if signed, construct and deliver the herein described dental restoration. Client shall be responsible for all fees, costs, charges, and expenses expended or incurred in any suit or action for collection of past due amounts or enforcement of provisions of this Agreement. Questions, Please call 805-735-7888 PREPPREPARATIONARATION GUIDELINESGUIDELINES Restoration Checklist and Helpful Suggestions for Optimum Restorations VENEER PREPARATION STANDARD PORCELAIN LABIAL ALL-CERAMIC/COMPOSITE PREPARATIONS MARGIN PREPARATION BUCCAL LABIAL 0.5 - 1.5 mm LINGUAL 1.0 - 1.5 mm LINGUAL 1.0 - 1.5 mm • Send a bite registration with any cases involving INTERPROXIMAL INTERPROXIMAL the terminal tooth of the arch or where there is no INCISAL 1.5 - 2.0 mm OCCLUSAL 1.5 - 2.0 mm posterior stop. 90° Shoulder 2.0 mm 1 mm Reduction • Send a pre-op study model with all anterior cases when possible Including Incisal Edge Laminate Reduction • Check for adjacent teeth for proper contact areas, and adjust if necessary. INLAY • Use a single, full arch tray for cases with ONLAY 2.0 mm min. 2.0 mm min. 3 units or more. 1.5 mm - 2.0 mm 1.0 mm Wall Thickness 1.5 mm - 2.0 mm • Take a shade before prepping teeth • Securely wrap impressions and models, and enclose any restorations in a small box No Cavo-Surface Bevels Laboratory Schedule Facial Section Proximal Section Local Courier Service: We offer twice-a-day courier service between the cities of Santa Maria and Santa Barbara. Once-a-day we visit Ventura, Ojai, Oxnard, Santa Paula, Paso Robles, Atascadero, San Luis Obispo, Morro Bay, and Cayucos for case pickup and delivery. Call (805) 735-7888 for case pickup or more info. Mail Service: We use UPS/FedEx to pickup and deliver cases statewide & nationally. For shipping supplies, call 800.585.3111. Please note that the schedule listed below includes the number of days the case will be in the laboratory. Shipping days should be added onto lab days when determining when the case will get back to your office. Denture Repairs & Reline: Santa Maria through Santa Barbara only: • Same Day Delivery: Case must be picked up by morning delivery driver to have it delivered back same day. • Next Day Delivery: Case picked up by afternoon delivery driver will be delivered the next Morning by noon (Friday afternoon pickup, delivered Monday by noon). Nipomo to Paso Robles / Ventura, Camarillo, Oxnard, Santa Paula only: • Next Day Delivery: Case picked up by our delivery driver will be delivered early next Afternoon.

Crown & Bridge Removables Guards/Splints/ RUSH CASES! Zirconia, 3 units or less...... 3 days Partial Frame...... 10 days Ortho WE CAN ACCOMMODATE RUSH Lithium Disilicate, 3 units or less...... 3 days Set Partial Denture...... 5 days CASES. CALL FOR TIMELINE AND Guards...... 5 days Zirconia, 4 units or more...... 5 days Process Partial Denture...... 5 days RUSH FEES! Splints...... 5 days Lithium Disilicate, 4 units or more...... 5 days Set and Wax Full Denture...... 5 days Sleep Apnea Appliance...... 10 days 800.585.3111 PFM...... 10 days Process Full Denture...... 5 days Space Maintainer...... 10 days Full Cast...... 10 days DuraFlex, Visiclear, includes try-in & finish...... 10 days Hawley Retainer...... 10 days Diagnostic Waxups...... 5 days Custom Tray...... 3 days Robertson Dental Lab is committed Temporary Crowns...... 3 days Occlusal Rims and Base Plates...... 3 days Aligners to providing you and your patients with Stayplate - 3 Teeth or Less...... 3 days high-quality, on-time dental restorations Implants Stayplate - 4 Teeth or More...... 5 days Aligners, Digital Treatment Plan...... 3 days that meet your expectations and Valplast Process...... 5 days Aligners, Aligner Fabrication...... 7 days specifications every time. Our CDT’s are Complete Implant...... 12 days here to help guide you through even the Implant Crown on Solid Abutment...... 10 days Emergency Replacement Denture...... 5 days Reset...... 5 days Snap-On Smile most difficult cases. Experience the Implant Crown on Solid Abutment...... 10 days Robertson Advantage today! Implant Temp with Titanium Abutment. 2 days Rebase...... 3 days Snap-On Smile...... 6 days