1. DESIGN RX FORM (DENTURE)
▢ NEW CASE
▢ OLD CASE REF. #____________
CEBU DENTAS INTERNATIONAL INC.
2nd Floor Unit 204 TGU Tower, Cebu IT Park, Apas Cebu City, 6000
Tel
Rest Areas :
◯ Lab Select ◯ *Standard design if an option is not selected.
DESIGN INFORMATION
REQUEST
Company Name : Patient Name :
RX Date : Order No. :
Finish Date : SEX : M / F
Age :
TURNAROUND TIME
◯ 12 HOURS ◯ 24 HOURS
ITEMS ENCLOSE
◯ Scan Data ◯ Picture ◯ Other
INSTRUCTIONS
DENTURE:
◯ Full Denture ◯ Non Clasp Denture ◯ Partial Denture
Major Connector :
Maxillary
◯ Lab Select ◯ Horseshoe　◯ Open Horseshoe ◯ Palatal Strap 　　　　　　　 ◯ Palatal Plate ◯ A-P Palatal Strap ◯ Unilateral / Nesbit
Mandibular
◯ Lab Select ◯ Lingual Bar ◯ Lingual Plate ◯ Labial Bar
◯ Lingual with Kennedy Bar ◯ Unilateral / Nesbit
Clasp Options :
◯ Lab Select ◯ I-Bar ◯ C-Clasp ◯ C-Reverse-Action Hairpin Clasp