The Old Surgery, 14 Cole Bank Road, Hall Green, Birmingham B28 8EX Tel: 0121 777 1414 Email: [email protected] www.aestheticdentallab.co.uk MHRA Reg. No. CA001036 CROWN & BRIDGE PRESCRIPTION
Job No.
British Dental Technology Disinfected Off icial Sponsor | 2012
Surgeon & Address CROWN & BRIDGE WORK
CAD-CAM Non-Precious Precious Porcelain Bonded Crown Porcelain Bonded Bridge Non-precious crown silver 33% + Silver Crown A custom made device for the exclusive use of: Patient 33% + Yellow Crown 60% + Yellow Crown Please tick service required: Inlay 60% + yellow Private NHS Post & Core Maryland Bridge (Sand blasted, etched) Date Required Please date day before appointment Rochette Bridge (Sand blasted, etched) Staining & Characteristics Pontic Design: METAL FREE RESTORATIONS Shade: ...... Zirconia E-Max Collar and Metal Design: Composite
Porcelain Veneer - to cover natural coloured teeth
Occlusion: Porcelain Veneer - for mildy discoloured teeth
Porcelain Veneer - for severe discolouration
PJC Special Instructions Porcelain Inlay Dentine Bonded Crown Temp. Crowns/Bridges
IMPLANTS - all systems accepted Straumann Astra 3i Ankylos Nobel Biocare Bicon Neoss Other Bio-Horizons
THIS COMPLETE APPLIANCE HAS BEEN WHOLLY LABORATORY USE ONLY MANUFACTURED WITHIN THE UK
CONTRACT When signed for release, this device conforms to the relevant essential requirements set out in
Annex 1 of the Medical Devices Directive (93/42) EEC). If there are any essential requirements not Rubber Imp. Crown to shade match Face bow met these will be stated. This statement does not apply to repairs etc. of a pre-manufactured Alignate Bite registration Implant component appliance. The laboratory will manufacture the appliance as per the prescription, it is the
prescribers responsiblity to ensure that the prescription is completed correctly and complies to Study model Photograph Other dental regulations.
Approved for manufacture by: Released by: Metal Work Weight Ceramist
White Copy: Surgery Copy • Yellow Copy: Patient Statement of Conformity • Blue Copy: Lab Keep away from extreme hot and cold. Non sterile appliance