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(312)2566860

RIVER CITY DENTAL LABORATORY

1509 RAPIDS DR. • SUITE 308 • RACINE, WI 53404

PHONE: (312) 256-6860 • EMAIL:rivercitydentallab8@gmail.com

Dr.(Required)

First

Case Materials Enclosed

Impressions

Bite Registration

Models

Patient Name(Required)

First

Supply Requests

Rx Forms

Shipping Labels

Boxes

Other:

Today's Date

MM slash DD slash YYYY

Due Date by 5 p.m

MM slash DD slash YYYY

Signature

Fixed Restoration

Economy Denture Set

Upper

Lower

Premium Denture Set

Upper

Lower

Immediate Denture Set

Acrylic Partial Denture

Flipper 1-3 Teeth

Metal Frame (Allow 2 weeks)

Reline Per Plate

Wax Bite (4 days in lab)

Custom Trays (4 days in lab)

Night Guard/3D Splint

Denture Repair Starting at

Clasp

Ball Clasp

Wire Clasp

Other

Crown & Bridge

Occu Stain

Light

Dark

Medium

HT Solid Zirconia

Multi-layered Zirconia

Extreme Solid Zirconia

Stardust - Multi Strength Zirconia

E-Max Solid Crown

E-Max Inlay/Onlay

Multilayer PMMA Crown (Zirconia 7 days in lab)

Porcelain Fused to Semi Precious White Gold

Porcelain Fused to Metal

Porcelain Fused to high Noble Yellow Golden

Full Cast Yellow Gold Crown

Yellow Gold Onlay Inlay (PFM is 15 days in lab)

Tooth#

Shade:

Stump Shade:

Tissue Shade:

Pink

Light Pink

Meharry

gingival / incisal

Teeth's Selection

1

2

3

4

5

6

7

8

9

10

11

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13

14

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Tick the tooth numbers according to the mentioned below described picture.

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rivercitydentallab8@gmail.com
1509 RAPIDS DR. SUITE 308 RACINE, WI 53404
(312)2566860

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