K. DENTAL LAB
254 Soi Ladprao 94 Srivara Rd.
Wangthonglang BKK Thailand 10310
TEL : (662) 5300315-6 , 5307552-3
FAX : (662) 5300314
www.dentalk.com

ISO9001:2000 Certificate             


ORDER FORM

NO. ___________________

DENTIST __________________________________
CLINIC ____________________________________
PT 'S NAME _______________________________
DATE ______________________________
FINISH _____________________________
AGE ______________       M       F

        CROWN        BRIDGE
KIND OF WORKS
  PORCELAIN ________________
  IN-CERAM _________________
  EMPRESS _________________
  PROCERA _________________
  CERCON __________________
  FULL METAL _______________
  PIN _______________________
  TEMP Cr __________________
  OTHER____________________
 

CERAMICS AlLLOY
  Non-Precious              Palladium
  Semi-Precious 51%     _________
  Precious 87%

ALLOY FOR FULL METAL CROWN
  Non-Precious              Precious 70%
SPECIAL INSTRUCTION
  La Por. Margin _________________
  B Metal Margin _________________
  No Metal Margin ________________
  3/4 Occlusal Metal ______________
 WORKING M.  ANTA M.  BITE  DIE
 IMPRESSION TRAY  STUDY M. ________
Try in

  Try in Wax 
  Try in Metal Substructure 
  Try in Contour

PONTIC DESIGN

SHADE / NOTE __________________________________________________________________

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_________________________Signature