New Client Information & Preferences

In our ongoing efforts to consistently provide the highest quality restorations and customer service to our clients, we ask that you take a few moments to complete this questionnaire for our future reference.

Doctor Name

Practice Name

Address

City, State, & Zip

Phone #

Fax #

Email

Hours (Mon - Fri)

to

Hours (Sat)

to

Hours (Sun)

to

Assistant(s) Name(s)

Office Contact For:

Billing Questions

Scheduling Questions

Technical Questions

Doctor's Birthday (m/d/y)

Problems with Previous Lab

Preferences

What is your preferred type of alloy for Porcelain Fused to Metal cases?

Non-Precious
Semi-Precious
White High Noble
Yellow High Noble

What is your preferred type of alloy for All Metal (Full Cast) cases?

Non-Precious (White)
Non-Precious (Yellow)
Semi-Precious (White)
Full Cast Gold (Yellow)

Contacts

Normal
Broad
Light
Heavy

Occlusion

Out of Occlusion
Light
Normal
Heavy

Occlusal Staining

None
Light
Medium
Heavy

Type of Margin Normally Used

Chamfer
Feather
Shoulder
Beveled Shoulder

If occlusal clearance is a problem, what would be your preferred method of correction?

Metal Occlusal
Reduce Prep
Send Reduction Coping
Relieve Opposing
Call Doctor

Can we make this a permanent note for future cases?

Yes
No

Diagnostic Wax-Ups - Wax Color

White
Gray

Additional Instructions or Comments

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