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LSK121 On Line RX Form
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Due Date
---MONTH---
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2024
2025
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
Zirconia
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
Finish
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
Other:
Custom Tray
Bite Block
Wax Setup Try-in
Reline
Repair
Rebase
Partial Dentures
Metal Free
FiberFlex™
Duracetal®
Flipper
Essix®
Clasps
Metal Cast Frame
Metal
Pink Tissue
Tooth Colored
Clear Fixed
Frames
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
Notes
Please Send
LSK121 Rx
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