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425 Dental
Paramount Lab Communication
Comments
This field is for validation purposes and should be left unchanged.
Patient Name
(Required)
First Name
Last Name
Team Member Name
(Required)
First
Doctor
(Required)
Dr. Oleg
Dr. Nikole
Dr. Sakai
Dr. Snipes
Other (Please write in e-mail address)
Submission Request Regarding:
(Required)
Crown
Implant
Bridge
Night Guard
Retainer
Other (Write in NOTES)
Tooth Number
Time-Sensitivity
RUSH SERVICE $50
Name
First
Last
Email
Communication Needed (Specify in Notes Surface of Issue and Details as Needed)
(Required)
Open Margin
Open Contact
Wrong Shade
Pre-treatment Scan Reproduce Shape
Pre-treatment Scan Reproduce Bite NOT SHAPE
Shade Photo Being Emailed
Fabricate Maxillary 3D printed night guard, flat plane occlusion
Fabricate Mandibular 3D printed night guard, flat plane occlusion
Upper/Lower Bleach Tray
Fabricate upper essix retainer
Fabricate lower essix retainer
Fabricate one set of essix retainers
Fabricate 4 sets of essix retainers
Other (Write in NOTES)
Upload a shade photo (if applicable)
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB, Max. files: 3.
Notes
