UNIVERSAL Rx • - glidewelldental.com

1 UNIVERSAL Rx Dr. Name_____ Phone #_____. Acct. #_____ Patient Name_____. First Last 4141 MacArthur Blvd. Newport Beach, CA 92660. See Reverse for Working Times Address/Email_____ Deliver by 5 on _____. 800-854-7256 Fax 800-411-9722. Enclosed with Case: Impressions Models Bite Photos Other:_____. PROVISIONAL RESTORATIONS ZIRCONIA/ALL-CERAMIC RESTORATIONS FINAL SHADE PONTIC DESIGN. BioTemps Provisionals BruxZir Full-Strength* (1,150 MPa) BruxZir Esthetic (870 MPa). Reinforcement: None Wire* Fiber Obsidian All-Ceramic IPS (anterior). Cast-Metal Prismatik Clinical Zirconia IPS (posterior) * . Transition C&B Smile Transitions Lava Zirconia Abutment #(s)_____ STUMP SHADE MARGIN AND METAL DESIGN. VIVANEER VENEER Must indicate prepped tooth shade for all-ceramics Pontic #(s)_____ Total units_____ Conventional-Prep: Splinted* Cement-on Implant BruxZir Esthetic Obsidian IPS Minimal-Prep: * . Individual Units Screw-Retained Implant Labial Butt Junction Junct.

2 Collar Excl. Cusp Incl. Cusp Amount of prep reduction: 1 mm* 2 mm Obsidian IPS OCCLUSAL STAINING. IF NO OCCLUSAL CLEARANCE. Perio treatment: Prepare tooth below gingival OBSIDIAN FUSED TO METAL None Light*. on tooth #(s) _____ by _____ mm Call doctor Spot opposing Metal occlusion Non-Precious* White Noble White High Noble Medium Dark Pontic site healing: Prepare ovate socket on tooth Metal island Make this a permanent note #(s) _____ by _____mm SCREW-RETAINED RESTORATIONS. BruxZir Full-Strength* Obsidian Fused to Rx DENTURES/FLIPPERS/FLEXIBLE PARTIALS White Noble (w/ Ti-Base). Denture Flipper Valplast tcs DuraFlex BruxZir Esthetic Obsidian Fused to White (w/ Ti-Base) High Noble Custom tray Bite rim Wax setup try-in Finish IPS (w/ Ti-Base) Prismatik CZ (w/ Ti-Base). Kenson Teeth (Included at no extra charge). CUSTOM ABUTMENTS. Premium Brand Teeth (Extra charge applies). Shade_____ Brand_____ Mould _____. Titanium* Gold-Tone Titanium Gold Alloy Zirconia w/ Ti-Base BIOMET 3i Encode NIGHTGUARDS/RETAINERS Prepare existing abutment Upper Lower Scan/Save File COMPOSITE RESTORATIONS.

3 Comfort H/S* Astron CLEAR splint Camouflage NanoHybrid Composite Fiber Reinforcement (hard/soft) (hard processed acrylic). Soft nightguard Comfort (hard). FULL-CAST RESTORATIONS. Clear-Lock Retainers for Life: Noble-Cast 42 YN (2% Au) JRVT YHN (77% Au). set of 2 set of 4 set of 6 Noble-Cast 45 YN (40% Au) Non-Precious Clear ortho Hawley QCM Clear-Wire Noble-Cast 60 YHN (57% Au)* White Noble Noble-Cast 67 YHN (64% Au) WHN (45% Au). SNORING/SLEEP APNEA APPLIANCES OcclusalGold YHN (73% Au) Post & Core Silent Nite sl* EMA Scan/Save File Buy 1 dreamTAP METAL PARTIALS. Buy 2 and save TAP 3 TAP Vitallium 2000* Vitallium 2000 Plus tcs/Vitallium Valplast/Vitallium Wironium tcs/Wironium PLAYSAFE MOUTHGUARDS. Jr Lt Lt Pro Med* Hvy Hvy Pro Metal frame try-in Printed frame try-in Frame w/occlus. rim Frame w/setup try-in Finish Scan/Save File Signature_____ License #_____. Helmet strap Specify color(s) on Rx (see reverse for limited warranty details). 2018 Glidewell Laboratories *Standard unless specified otherwise GL-421-080918.

4 IN-LAB WORKING TIMES. Please allow full working time for each product selected. Working times are NOT guaranteed and do NOT include weekends or holidays. Rush service available on most products but must be prescheduled (see below). Obsidian Fused to days BioTemps days Metal Partial to 12 days Diagnostic days With cast-metal days Occlusion rims/Custom 3 days Obsidian w/ days With cast-metal substructure over days Denture setup 5 days Custom days Screw-retained over days Finish after setup 5 days All-ceramic screw-retained days Smile Transitions days Denture try-in to 5 days Obsidian Fused to Metal screw-retained days Transition Crowns & days Valplast/tcs setup teeth in 5 days All-ceramic/zirconia days Partials & Dentures Finish after setup 6 days Full-cast days Metal Frames ..6 days Valplast/tcs start to 7 days Composite days Metal Frame with teeth and days Denture soft liner/acrylic repair or 5 days Fiber-reinforced days Finish after setup days Partial 5 days PlaySafe mouthguards/Silent Nite 4 days TAP/TAP 3/ 5 days All rush cases must be prescheduled by calling 800-944-7874.

5 Before the case is shipped. Time of pickup and delivery may affect turnaround time. Comfort H/S Bite 4 days Nightguards/Bleaching 4 days PREPARATION GUIDELINES. Anterior: BruxZir Anterior: BruxZir Anterior: Obsidian Anterior: Obsidian TERMS AND WARRANTY INFORMATION. Full-Strength Esthetic and IPS Fused to Metal We honor VISA, MASTERCARD, AMEX. and DISCOVER. TERMS: Cost of collection of any account will be paid by the customer. All accounts are payable within 30. days of statement date. Accounts not paid within the stated terms will be subject to COD status and a late charge of 2 percent of the unpaid balance. Prices subject to change without notice. Rx must be A. 1 mm ideal reduction ( mm minimum) A. mm ideal reduction ( mm minimum) A. 1..5 mm ideal reduction A. 2 mm ideal reduction ( mm minimum). ( mm minimum). enclosed with original case submission. B. Chamfer or shoulder margins preferred. B. C hamfer or shoulder margins preferred B. Chamfer or Shoulder margins preferred Feather-edge OK C.

6 Labial and lingual walls must be B. Shoulder margins preferred C. Labial and lingual walls must be C. Labial and lingual walls must be convergent convergent C. Labial and lingual walls must be convergent NO-FAULT REMAKE POLICY: Glidewell D. Preparation should be cut in three planes D. Preparation should be cut in three planes convergent D. Preparation should be cut in three planes Laboratories is pleased to process all remakes or D. Preparation should be cut in three adjustments at no additional charge if requested planes within the warranty period and accompanied by the return of the original appliance. Posterior: BruxZir Posterior: Obsidian Posterior: Obsidian Full-Strength and IPS Fused to Metal LIMITED WARRANTY/LIMITATION OF LIABILITY. For warranty terms and conditions and limitation of liability, visit -warranties/. All Restorations Made in the USA. A. 1 mm ideal reduction ( mm minimum) A. 1..5 mm ideal reduction A. 2 mm ideal reduction ( mm minimum).

7 B. Chamfer or shoulder margins preferred. ( mm minimum) B. Chamfer or Shoulder margins preferred Feather-edge OK B. Shoulder margins preferred C. Buccal and lingual walls must be C. Buccal and lingual walls must be convergent C. Buccal and lingual walls must be convergent D. Preparation should be cut in three planes convergent D. Preparation should be cut in three planes D. Preparation should be cut in three planes