ILLUSION DENTAL LABORATORY PVT. LTD.
Order Form

Doctor's Name : Due Date :   Ceramic Restoration/Alloy Choice Non Precious Nickel Free Precious Case Design Porcelain  Porcelainfacing Maryland Bridge Metal Free Vita - Inceram Veenar/ Laminate Implant Implant Bar Precision Attachment Finishing Instructions Metal Try In  Bisque Finish Direct Finish Cast Partial Frame Work Bilateral Cast Case

402, Akruti Arcade, J.P Road, Near Andheri Sports Complex, Andheri(W), Mumbai, India - 400058. Tel : [00 91 22] 56963058 / 56963059 Fax : [00 91 22] 56998868 Email id : illusiondental@rediffmail.com Website : http://www.illusiondentallab.com No of Units 8 7 6 5 4 3 2 1   1 2 3 4 5 6 7 8 8 7 6 5 4 3 2 1   1 2 3 4 5 6 7 8 Mamelons Incisal Translucent Crack Line Basic Shade Characterisation Occlusal Stains Attrision Spots Bands Pontic Design

Patient's Name : Age Sex Patients Shade Desiers Vitapan Classic Chromascop Vitapan 3D -Master Other Surface Texture Luster Less Defined Smooth Matte Coarse Gloss Implant Information Type of Implant Implant Size Veneers : Purpose of Veneers Diastema Closer Correct Malalignment Increase Length Change Colour Color of Prepared Teeth (Place Indicate on Drawing) Tetracycline  Severe Hypocalcification Shade Characterisation Shade Prepared Teeth Shade of Veneer Incisors Canines Proximal Finish Line (Place Indicate location of Proximal Finish Line) Lingual Proximal Labial Note : All finishing lines must be undercut free. Procelain veneer's have a labial or incisal labial path of Insertion Doctor Name     Expected Date: