Digital RX

Doctor's Name

License #

Street Address




Email Address

Patient Name

Phone Number

Patient Sex

Patient Age

Due Date

Which implant system are you using?

Which implant system will you use during surgery?

Number of Implants

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