Removable Prosthetic Rx

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Remove Rx

Laboratory Procedure Prescription

Required Information

Extractions

Please CHECK all teeth to be extracted and replaced

Case design


Acrylic Shade (Required)





(Vita is default)

Dentures















Partials

Base Material (non-metal)

Material Framework

Tooth Type

Design

Nightguards/splints

Other

(Clasps type)

RX Specific Instructions

Please provide any photos, study models, diagnostic casts with case

Email photos to: cs@xdentcenter.com

The person signing this form is an authorized representative and, together with the dental practice, accepts responsibility for payment of all associated charges, including any legal, collection, and additional fees incurred by XDENT LAB should the account proceed to collections or litigation.

*Standard design if an option is not selected
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XDENT LAB Co.,LTD

Factory 1: 101 Tran Van Kieu Street, Ward 10, District 6, HCMC, Vietnam

Factory 2: Kizuna 3 Industrial Park, Long An Province, Vietnam

www.xdentlab.com

**The person signing this form is an authorized signer and, along with the dental practice, accepts responsibility for payment of all related charges, as well as any legal costs, collection and other fees incurred by DDS Lab in the event the account is sent to collections or litigation. © 2021 DDS Lab. All rights reserved.