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Schack Dental Presciption Pad
Submit your prescription online using this form! No paper required.
Dr. Name
*
First
Last
Dr. Phone #
Patient Name
*
First
Last
Gender
M
F
Enclosed With Case
*
Opposing
Bite
Analog
# of Impressions
Old Bite
Shade Tab
Impression Post
Pictures
Partial
Study Model
Other
Enclosed with Case (Other)
*
Choose a Service
*
Zirconia
All Ceramic
Full Gold
PFM
Implant
Zirconia
*
Zirconia Type
*
High Strength
Multi Shaded
Aesthetic
Layered
All Ceramic
*
All Ceramic Type
*
Emax
Emax Layered
Emax Multi
Full Gold
*
All Gold Type
*
High Gold
Semi Gold
PFM
*
PFM Type
*
Gold
Semi Gold
Non-Precious
Labial Margin
*
Metal
Porcelain
Butt 180º
Occlusion
*
Porcelain
Metal
Implant
*
Implant Brand
*
Implant Size
*
Implant Type
*
Custom
Stock
Choose 1
*
Titanium
Gold Hue
Zirconia
Shade
Upload Pontic Design Sketch
Drop files here or
Accepted file types: jpg, jpeg, gif, png, pdf.
RX Notes:
Doctor License
Doctor Signature
*