smiles with
crafty hands

404-394-4964

smiles with
crafty hands

Schedule A Consultation
404-394-4964

Faiz Dental Studio Prescription Form

Doctors Name *

Doctors Address *

Patients Name *

Patients Age

Sex Of Patient *MaleFemale

Restoration Type *CrownVeneerInlayOnlayDiagnostic Wax UpBridgeNot Applicable

Desired Shade *A1A2A3A4B1B2B3B4C1C2C3C4D2D3D4BL1BL2BL3Not Applicable

Material Choice *EmaxZirconiaEmpressFeldspathicGoldNot Applicable

Alloy Type *High NobelNobelYellow GoldWhite GoldNot Applicable

Implant Abutments *Custom MilledPre FabricatedCeramicTitaniumNot Applicable

Implant Brand

Implant Size

Stump Shade

Occlusal Anatomy *WornLightCopy ExistingImprove AestheticNot Applicable

Articulator Type *SamPlasticNot Applicable

Return Case To Doctor For *MountingDye TrimMetal Try InBisque BakeFinishNot Applicable

Enclosed *Shade TabPhotosArticulatorCrownNot Applicable

Office Needs *RXSafe BagsBoxesNot Applicable

Doctors Signature *

Doctors License # *

Upper Right *Tooth 1Tooth 2Tooth 3Tooth 4Tooth 5Tooth 6Tooth 7Tooth 8Please Select Any and All Teeth That Require Work As Outlined WIthin this Prescription

Upper Left *Tooth 9Tooth 10Tooth 11Tooth 12Tooth 13Tooth 14Tooth 15Tooth 16Please Select Any and All Teeth That Require Work As Outlined WIthin this Prescription

Lower Left *Tooth 17Tooth 18Tooth 19Tooth 20Tooth 21Tooth 22Tooth 23Tooth 24Please Select Any and All Teeth That Require Work As Outlined WIthin this Prescription

Lower Right *Tooth 25Tooth 26Tooth 27Tooth 28Tooth 29Tooth 30Tooth 31Tooth 32Please Select Any and All Teeth That Require Work As Outlined WIthin this Prescription