Digital RX – Crown & Bridge

Complete this online prescription and we’ll generate a PDF that mirrors our printed Crown & Bridge RX form. Attach it to your case upload or print and send with your physical case.

Date Sent

Due Date

Appt. Time

Doctor & Patient Info

Doctor

License #

Account #

Tooth # / Teeth

Patient Last Name

Patient First Name

Date Prepared

Age

Sex

Signature (typed)

Shade Information

Body Shade

Incisal Shade

Cervical Shade

Occlusal Shade

Material Selection

PFM

Noble white Base Other

Full Cast

High noble Noble Base

All-Ceramic

Zirconia e.max Other

Additional Options & Photos

Misc / Implant / Under Partial

Case Photos

You can select multiple JPG/PNG images. They will be added to the end of the RX PDF and scaled to fit.

If No Occlusal Clearance

Ridge Relief

Pontic Design

Vertical Dimension / Smile Design

Shimbashi Measurements

Existing 8–25 Goal

Existing 9–24 Goal

Adjusted

Midline Correct?

If "No", specify offset below.

Midline Offset

mm Direction

Smile Canted

Surface Characterization

Incisal Translucency

Cervical Warming

Surface Texture

Occlusal Stain

Hypocalcification

RX Instructions / Notes

Email a copy of this RX to rx@patriotdentallab.com