Inclusive Tooth Replacement System

GLIDEWELL 800-839-9755 Final Restoration Rx

LABORATORIES Fax 800-411-9722
18551 Von Karman Ave. • Irvine, CA 92612 glidewelldental.com Deliver by 5 p.m. on ❑ Call before starting case
Master Case: Ceramic Shade important instructions Abutment Margin Depth
Instructions Utilize the Custom Impression Coping
Patient Name:
included in the original shipment
Tooth Number: for this patient. Complete this Rx and Facial Mesial
return to Glidewell Laboratories with
Rx impression, opposing impression and bite
registration. Lingual Distal

Select Abutment Type If left blank, default values will be used

Inclusive Custom Abutments

Abutment Margin Design
❑ Titanium Abutment*
❑ Zirconia w/ Ti-Base
❑ Gold-Tone Titanium Abutment ❑ Shoulder for Chamfer for ❑
IPS e.max* BruxZir*
Select CROWN Type
❑ BruxZir Full-Strength* (1,150 MPa) Abutment Emergence Profile
❑ BruxZir Anterior (650 MPa)
All Restorations ❑ IPS e.max
Made in the USA
Screw-Retained Restorations
Indicate Shade Here ❑ Surgical ❑ Tissue ❑ No Tissue
Signature________________________________________ ❑ BruxZir Full Strength (w/ Ti-Base)* Placement Displacement* Displacement
Occlusal Staining:
❑ BruxZir Anterior (w/ Ti-Base)
License #________________________________________ ❑ None ❑ Light ❑ Med ❑ Dark ❑ IPS e.max (w/ Ti-Base) Contour and Occlusion Design
Embrasures: ❑ Closed* ❑ Open
TERMS AND WARRANTY INFORMATION Occlusion: ❑ Light* ❑ Ideal

Only $7 shipping per box each way (contiguous U.S. only; shipping charge varies for Alaska, Hawaii and Puerto Rico).
❑ Open____ mm ❑ Out
Contacts: ❑ Broad & Tight* ❑ Pinpoint
❑ Light
All Restorations Made in the USA
Restoration Pontic Design

We honor VISA, MASTERCARD, AMEX and DISCOVER.

TERMS: Cost of collection of any account will be paid by the customer. All accounts are payable within 30 days of statement ❑ ❑ ❑* ❑ ❑
date. Accounts not paid within the stated terms will be subject to COD status and a late charge of 2 percent of the
unpaid balance. Prices subject to change without notice. Rx must be enclosed with original case submission. If No Occlusal Clearance
❑ Call doctor
NO-FAULT REMAKE POLICY: Glidewell Laboratories is pleased to process all remakes or adjustments at no additional ❑ Spot opposing
charge if requested within the warranty period and accompanied by the return of the original appliance. ❑ Make this a permanent note in my master file
LIMITED WARRANTY/LIMITATION OF LIABILITY. For warranty terms and conditions and limitation of liability, visit *Standard unless specified otherwise
glidewelldental.com/policies-and-warranties/.
GL-2742-111017