661-325-3494
E-mail us
1017 Chester Ave, Bakersfield, CA 93301
Home
About Us
Services
Fixed Prosthetics
Removable Prosthetics
Implant Restorations
Cosmetic & Aesthetic Dentistry
Orthodontic Appliances
Occlusal & Sleep Appliances
Digital Products
Career
Contact Us
RX Form
Home
RX Form
Search for:
Search Button
Printable Version
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Dr. Name:
*
Practice Location:
Phone:
*
Patient Name:
*
Date:
*
Due Date:
*
Gender
M
F
Age:
Removable
Removable
Immediate Denture
Economy Denture
Premium Denture
Partial Denture Vitallium
Partial Denture Standard
Partial Denture Combo
Flexible Partial (Valplast)
Flexible Partial (TCS)
Stayplate
Name: Patient Date:
Splint
Clear Hard Soft Night Guard
Clear Hard Hard Night Guard
Soft Night Guard
Mouth Guard
Study Models
Hawley Retainer
Essix Retainer
Bleaching Trays
Crown/ Bridge
Full Contour Zirconia
Layered Zirconia
E-Max
PFM
PFG
Semi-Precious
Full Gold Crown
Porcelain Margin
Occlusal
Metal Margin
Lingual
Implant
Implant Brand:
Implant Size:
Implant
Screw Retained
Cement Retained
Custom Titanium
Other
Hybrid-Fixed Implant Restoration
All-on-4
Solid Zirconia
Denture- Titanium Bar
Overdenture Hybrid Restoration
Framework Design
1
2
3
4
5
Pontic Design:
1
2
3
4
5
Shade Option
Call to Discuss Case
Custom Shade
Shade:
Stump Shade:
Tooth Number:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Doctor's Signature:
Clear Signature
License Number:
Submit
