Universal RxQuick & secure: Fill out your prescription online in just a few clicks. Seat Date * Please provide the date the restoration needs to back in your office MM DD YYYY Doctor Information * First Name Last Name Practice Name * Email * Phone (###) ### #### Patient Information * First Name Last Name Gender * Male Female Age Final Shade * Enter the requested restoration shade (e.g., A2, B1, OM3, bleach shade, custom match). Prep Shade Indicate the underlying tooth or preparation shade (stump shade) to ensure accurate final shade matching. Photos submitted to lab * Confirm if supporting photos (shade tab, prep, tooth, or smile) were sent to shade@epicdentalstudios.com No Yes Tooth Number(s) * Specify the tooth or teeth to be restored (use standard numbering system). Contacts Specify proximal contact preference Ideal (natural contact point) Broad (wider contact for added stability) Pontic Design Ridge Lap Modified Ridge Lap Ovate Conical Hygienic/Sanitary Crown & Bridge: Zirconia Select the desired restoration type for this case. Functional Zirconia (extra strength) Aesthetic Zirconia (exquisite) Encore (Layered Ceramic Premium Aesthetics) Polish only-No glaze Zirconia restoration will be hand-polished only, without stain or glaze application. Yes: Polish Only No: I want stain and glaze Crown & Bridge: Lithium Disilicate Select preferred lithium disilicate material. LiSi Press® (GC America) IPS e.max® (Ivoclar) Encore (Layered Ceramic Premium Aesthetics) Crown & Bridge: Full-Cast Select full-cast metal option Full-Cast Noble YN (2% AU, 35% Pd) Full-Cast High-Noble YN (52% AU, 5% Pd) Diagnostic Wax-Up Select diagnostic wax-up type Hand-waxed Digital/printed Provisional (PMMA) Do you want a provisional fabricated? Yes No Type of Reduction Guide Clear, suck-down (standard unless specified) Putty Key Index Removables: Denture Choose denture type Immediate Traditional Denture Options Custom tray Bite Rim Set-up Try-in Other Product Partial Material Options Acrylic Flexible Chrome Night Guard Upper Lower Hard Hard/Soft Soft Sleep Appliance Only one option at this time. EMA Essix Retainer Upper Lower Implant Design Manufacturer Preference OEM (Genuine Mfg. Components) Compatible Components Implant Option Screw-Retained Cement-Retained Screw-Retained Options Screw-Retained ONLY Ti Base Abutment Custom Titanium Abutment Cement-Retained Options Cement-Retained ONLY Ti Base Abutment Custom Hybrid (Zirconia) Abutment Pre Stock Abutment Implant Emergence Profile Select desired emergence profile Full Anatomical (natural contour) Tissue Displaced (standard unless specified) No Displacement (straight profile) Special Instructions: Doctors Signature * Entry of name serves as digital signature and approval of this Rx. Thank you!
