Lab Script Doctor's Name * Dr. First Name Last Name License Number Practice Name/Location Contact Email Address * Patient Name * First Name Last Name Desired Return Date (by 5:00pm) * MM DD YYYY Office Phone (###) ### #### Restoration Type (select all that apply) * Inlay/Onlay Overlay Implant Crown Veneer Bridge All-on-X (FP1/2) All-on-X (FP3) Occlusal guard Others Tooth Number(s) & Implant Brand(s)/Connection * Material Requested * Zirconia - Full Contour PFZ/Layered Zirconia Lithium Discillicate (e.max) PMMA (on prepped teeth or implants) PMMA (shell) 3D Printed Resin Others Tooth Shade & Shade Guide * Stump Shade Photos Sent * Please note that all anterior teeth, photos are required Yes - Emailed to orders@kor-labs.com Yes - Dropbox Yes - Uploaded below No Photos Design Review Requested * Yes No Specific Instructions Thank you!
