LSK121 On Line RX Form

Doctor's Name

License #

Street Address




Email Address

Patient Name

Phone Number

Patient Sex

Patient Age

Due Date

Implant Integrated Packages

Screw-Retained Implant Integrated Package™

Porcelain Fused to Titanium Screw-Retained Crown
Zen Enamel Crown with Custom Abutment
Zen Enamel Layered Crown with Custom Abutment
Kosmic LiSi Monolithic Press Crown w/Custom Abutment
Kosmic LiSi Layered Crown with Custom Abutment

Cement-Retained Implant Integrated Package™

PFM Crown + Ti-Based Custom Abutment
Zen Enamel + Ti-Based Custom Abutment
Zen 1200 + Zirconia Custom Abutment
Kosmic Press Layered + Zr Abutment
Monolithic Press + Ti Abutment
Monet Pure Zirconia Layered+ Ti Abutment
Monet Pure Zirconia Layered + Zr Abutment

Syton™ Full-Mouth Implant Packages

Syton™ 1800 Implant Ovedenture
Syton™ 2200 Attachment Bar Overdenture
Syton™ 3500 Screw-Retained Hybrid Acrylic
Syton™ 4900 Screw-Retained Hybrid Zirconia
Syton™ 5000 Removable Monolithic Zirconia
Syton™ 7-Star Ceramic Zirconia

Resilient, Long-Term Proversional Service

Temporary Implant Provisionals #
Cosmetic Temporary Provisionals #
Metal Linguals Provisionals #
Fiber Provisionals #

All-Ceramics Posterior

GC Initial™ LiSi® Press (High Strength Lithium Disilicate)

Kosmic Monolithic Press
Kosmic Press Layered


Zen Enamel Monolithic
Natural Posterior (Zirconia Occlusion)
Monet Pure Zirconia Layered

All-Ceramics Anterior

LiSi® Kosmic Press
Layered Monolithic
Hollywood Veneer

Monet Pure Anterior Zirconia Layered
VIP Single Central Anterior Service
Monet Pure Zirconia Layered

Metal Ceramics

LiSi® Kosmic Press
Non Precious (Base) Semi-Precious (Base) White Precious (High Noble) Yellow Precious

Marginal Design
No Metal Showing Porcelain butt
Lingual Metal Band Lingual distal band
Extra Thin 360° metal band

Maryland Bridge

GC Gradia Ceramic Composite
Fiber Reinforced
Monet Pure Zirconia Maryland Bridge
Metal Ceramic Maryland Bridge

Return For

Die Trim
Bisque Try-In
Metal Try-In

If No Occlusal Clearance

Metal occlusion
Metal island
Call doctor
Reduce opposing
Reduction coping

Full Dentures

LSK Deluxe Denture
Overdenture w/attachments Metal Mesh
Attachment Bar Overdenture
Custom Tray
Bite Block
Wax Setup Try-in

Partial Dentures

Metal Free
FiberFlex™ Duracetal® Flipper Essix®

Metal Cast Frame
Pink Tissue
Tooth Colored
Clear Fixed

Frame Only
Frame w/ Rim
Frame w/ Teeth Setup Try-In
Frame w/ Teeth Process Finish

Night Guards/Splints/TMJ Appliances

Choose Arch:
Upper Lower

Choose Design:
Anterior Guidance Flat Plane Canine Rise

Soothing Protect Splint (hard & soft) $79
Soothing Protect Splint (soft) $79
Soothing Protect Splint (hard) $79
Occlu-Balance (Clear hard acrylic)
Occlu-Ease (Clear hard/soft acrylic)
Occlu-Protect (Clear hard acrylic)
Occlu-Soft (Clear pliable acrylic)
Occlu-Ever (Clear thermoplastic resin)
Occlu-Snug (Biocryl)
Occlu-Dual (Biocryl)
Occlu-Flex (Biocryl)
Surgical Stent (Biocryl)

Treatment Plan Wax-Up

Teeth #
Crown #

Veneer #
Implant #

Prep Guide Model
Mount w/Bite Correction CR CO
Putty Matrix Guide from Wax-Up
Long-Term Provisional
Bite Correction
Clear Stent for Temporary


Please Send

LSK121 Rx
Case Boxes
Bio Bags