425 Dental
Paramount Lab Communication
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
Other (Write in NOTES)
Tooth Number
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
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
Name
This field is for validation purposes and should be left unchanged.
