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INOVA INTERACTIVE FORM
DR/OFFICE Name
(Required)
Phone Number
(Required)
Number
(Required)
Untitled
(Required)
Date
(Required)
MM slash DD slash YYYY
Patient Name
(Required)
Due Date
(Required)
MM slash DD slash YYYY
SINGLE
BRIDGE
MALE
FEMALE
Untitled
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ALL PORCELAIN RESTORATIONS
ZIRCONIA RESTORATIONS
IPS e.max CROWN
IPS e.max VENEER
IPS e.max INLAY/ONLAY
IPS e.max NO-PREP VENEER
PORCELAIN FUSED TO ZIRCONIA (PFZ)
ProXZir FULL-STRENGTH (14,00 MPa)
ProXZir ANTERIOR (650 MPa)
ProXZir INLAY/ONLY
CAD/CAM CUSTOM ABUTMENTS
IMPLANT RESTORATION
NON-PRECIOUS
SEMI-PRECIOUS
ZIRCONIA
PREP STOCK ABUTMENT
MODEL ANALOG
NON-PRECIOUS
HIGH NOBLE
ProXZir FULL-STRENGTH
SEMI-PRECIOUS
IPS e.max
PFZ
REMOVABLES
PORCELAIN FUSED TO METAL (PFM)
UPPER
LOWER
FULL DENTURE
ACRLIC PARTIAL
CUSTOM TRAY
SET-UP TEETH TRY-IN
TCS PARTIALS
CAST METAL PARTIALS
BITE BLOCK
PROCESS TO FINISH
NON-PRECIOUS
SEMI-PRECIOUS
HIGH NOBLE
NIGHTGUARD
UPPER
LOWER
FLIPPER/NESBIT
UPPER
LOWER
HARD
BLEACHING TRAYS
SPORT GUARD
SOFT
SOFT INSIDE HARD OUTSIDE
TCS NESBIT
ACRYLIC FLIPPER
TEETH #(S) (UP TO 3 TEETH)
PROVISIONAL RESTORATIONS
ACRYLIC TEMPS
CAD/CAM TEMPS
REINFORCEMENT
WIRE
ABUTMENT #(S)
PONTICS #(S)
TOTAL UNITS
AMOUNT OF PREP REDUCTION:
lM.M*
2M.M*
PREFERENCES
Enclosed with Casa
OCCLUSAL CONTACTS:
LIGHT
MEDIUM
HEAVY
IMPRESSION
MODELS
OTHER
PHOTOS
BITE
INTERPROXIMAL CONTACTS:
LIGHT
MEDIUM
HEAVY
MARGINS:
STANDARD
METAL
PORCELAIN
DISAPPEARING
IF NOT ENOUGH OCCLUSAL CLEARANCEI
NOTIFY DOCTOR
MAKE METAL OCCLUSION
ADJUST OPPOSING & MARK IN RED
ADJUST TOOTH & MAKE REDUCTION COPING
Dr’s Signature:
Signature
License #:
SPECIAL INTRUCTIONS:
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