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 & 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 - 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