How to Complete an Rx Form for a Custom Tissue Former Please complete all of the highlighted areas . 1 Fill in the surgery date and time. 2 Fill in doctor and patient information. 3 Indicate implant manufacturer and planned restoration. 4 Indicate tooth numbers. 5 Select Surgical Drilling Device and Custom Tissue Former. 6 Complete signature.
Implant Solutions Rx Form Requirements
SURGERY DATE TIME
PAN # IMPLANT SOLUTIONS, LLC USE ONLY
PLEASE COMPLETE SECTIONS 1 - 4.
PATIENT NAME DOCTOR ADDRESS CITY, STATE, ZIP PHONE
1
FAX
INFORMATION NEEDED FOR PLANNING:
Implant Manufacturer
2
PLANNED RESTORATION: Crown & Bridge
Fixed Overdenture
Removable Overdenture
23 242526
7 8 9 10
27
22
6
11
28
21
5
12
29
20
4
13
3
19
30
3
14
Upper
Lower
31
18
2
15 16 17
32
1
Right
Left
Left
Right
FABRICATE : Conventional Scanning Appliance Treatment Plan Proposal : :
Temporary Crown Temporary Denture
Custom Tissue Former Custom Abutment
4
Flipper
Surgical Drilling Appliance
Essex Retainer
Notes:
Designing a Custom Tissue Former Video!
I hereby grant Implant Solutions, LLC permission to make minor changes to my plan as necessary.
LICENSE NO: Please return the appliance and disk to Implant Solutions, LLC IMPLANT SOLUTIONS, LLC Email: info@solutionsforimplants.com
SIGNATURE:
IS 501
71
Powered by FlippingBook