Patient Name: MOSES MIRACLE WORK DETAILS: Sl.

No :
Date: AAID CHENNAI

Required Date:

DENTCARE DENTAL LAB PVT. LTD. BAR CODE Sl. No :

NAS ROAD, 130 JN., MUVATTUPUZHA, KERALA, INDIA - 686 661
Ph : +91 485 2835112, 2835113
[email protected]

Order Date : 1/10/24 Required Date : 3/11/24 No of Days :

DOCTOR’S NAME : DR JUSTIN ONG KYWEN (AAID CHENNAI) PATIENT NAME : (IN BLOCK LETTERS)
M O S E S M I R A C L E
Clinic's Name : VIVIDENT DENTAL HOSPITAL
Age :
Address : Vallalar St, Ezhil Nagar, Selaiyur, Chennai, Tamil Nadu 600073, India
Gender Male ✔ Female Other
Phone : +91 73053 88325
New Case ✔ Repeat Case Thesis (specify details in notes)

DENTAL LAB WORK AUTHORISATION

CROWN & BRIDGE IMPLANT PROSTHESES
Crown Bridge Crown & Bridge ✔ Screw Cement C/Access Hole
Inlay/Onlay/Overlay Veneer

DC | MKT |2.1 | IS-CIR | RO DT 10-09-2024

Implant Supported Overdenture
Maryland Pontic Post & Core Fixed frame: Ti Milled Nova
Endocrown Rest
Frame work for Overdenture:
Wing 3/4th Crown PEEK Ti DMLS DMLS Nova
*Loop Connector *Post Crown
Hybrid Denture Screw Cement Provisional
DENTCARE ZIRCONIA
DentCare Prime Frame Work:
Platinum Plus M PFZ CB
Ti Milled PEEK
Premium Plus M PFZ CB
Standard Hybrid FrameWork
Classic M PFZ CB
Ti Milled PEEK Ti DMLS DMLS Nova
Ultra Plus M PFZ CB
BruxCare M (Post. upto 4 units) DentCare Acrylic: Plus Impact Inject Inject Pro

Solid Plus M (Post. upto 3 units) BPS (Ivoclar)

(M- Monolithic, PFZ- Porcelain fused to Zirconia, CB- Cut Back) Framework to receive Crown & Bridge (Malo)
Ti Milled Prime Ti Milled Ti DMLS DMLS
IPS e.max
With Die
e.max Press Staining Layering Individual
Without Die
e.max CAD Staining Layering (*As applicable) Joined

LAVA (3 M ESPE)
SHADE
Cervical a2 Lingual Metal Collar
Lava Premium M PFZ CB Middle
If no occlusal clearance
Lava Translucent M PFZ CB Incisal a3
Frame or Metal Island
Lava Essential M PFZ CB Shade Guide vita classical
*As applicable

Discoloration* Yes No Reduction Coping Adjust Antagonist

PEEK Stump Shade
JUVORA ✔ LC-Facing LC-Full Coverage Antagonist to be restored later
Vital Non vital Composite Metal
Bio HPP M LC-Facing LC-Full Coverage
Gingival Shade* Yes No
LIGHT CURE COMPOSITE (Metal Free) Stains and Effect If interproximal space is less
Crown Inlay Onlay/Overlay Veneer Rest Enamel Cracks White Spot Other
Adjust adjacent Expose frame
Occlusal Staining
METAL/METAL CERAMIC No ✔ Light Medium Dark
Full Metal
DentCare DMLS (CAD/CAM) Digital photographs ✔ ✔
PFM-Facing Perfect Infra Under
DentCare Nova WhatsApp: Email:
PFM 9539377711 [email protected]
DentCare Magna LC#-Facing Occlusal Contact
MISCELLANEOUS
Precious/Semi-Precious Alloy LC#-Full
Digital Smile Design Digital Mockup
Coverage
Ornamental Gold ** Digital Stump Preparation 3D Printed Model
Ceramic
Coating CAD Image
NPG **(Non Precious) Putty Index
Composite Vacuum Formed Template Broad
Titanium ** Milled DMLS Coating Light Cure Special Tray
Customized Abutment Proximal Contact
DENTCARE PERMAPRINT Implant Special Bite Implant Bite Block ✔ Point
DENTCARE LUMINER Partial Surface Full Surface Teeth Setting Trial Jig Trial
Frame Work Trial Frame Work with
PROVISIONAL/TEMPORARY
Teeth Setting Trial
PMMA (CAD/CAM - Milled)
Mockup Pontic Design
CAD/CAM (3D Printed)
Sanitary Ridgelap Modified Bullet Ovate
Heat Cure Acrylic Self Cure Acrylic
Is this a full mouth rehabilitation case?
Yes: Planned On Going No
PTO
 ENCLOSED ITEMS (Mention Number Against Each Item)
Articulator (Mention Company):-
Own.....................................
Facebow(Mention Company):-
Own......
Own................................... ........................................
Implant screw driver ........................................................
Implant Replica (Lab Analog) .........................................
Impression Coping & screw ............................................
Stock Abutment & screw ................................................
Castable Abutment & screw ..........................................
Temporary Abutment & screw ......................................
Teeth set ..............................................................................
Sleeve/Burnout coping....................................................
Gnathometer........................................................................
Centric Trays........................................................................
OPG/CBCT............................................................................

DIGITAL IMPRESSIO FILE SENT VIA ITERO UNDER AAID CHENNAI CAMP
Notes:

Signature of Doctor :

Name of Business Executive : Doctor Seal :

Emp. Code : PN:

Parcel Received Time & Date: Unpacked By:

Component Received: For Office Use Only

Dental appliance information: This is a custom made dental device which is intended for the exclusive use by the patient. This device has been manufactured to satisfy the design, information, property and characteristics specified by the
dentist for the above patient provided by the dentist. All goods are supplied in a non-sterile condition unless otherwise stated and should not be subjected to extremes of heat and cold. It is recommended that the product shall be stored in
a clean and safe environment if not used immediately.