Client's details 　 　 　 　
Name of client: 　 　 　 　 E-mail: 　 　
Address: 　 　 　 　 　 　 　 　
Doctor's name: Tel: Fax: 　
　 　 　              Patient's details 　 　 　
Patient's name: 　 　 Impression date: 　 　 　
Chart's No: Re-call date: 　 Item: 　
Sex: 　 Age: 　 　 　 　 　 　
Payment: 　 　 　
　 　 　              Order details 　 　 　
Tooth No:
Type(Please circle): 　
　 PFM crown/bridge Full cast crown/bridge Cast post Cast Inlay/onlay Full ceramic crown Porcelain Veneer
　 Ceramic inlay/onlay Implant Other 　 　
Metal type: 　   Ni-Cr Co-Cr Titian alloy Silver alloy 　 　
　   Au 86% Au 73.8% Au 55% Cecornia system 　
Porcelain shade guide:
  Vita universal :
　 Vita 3D
　 　
　 　
  Shufo 16:
　 Shufo 19:
Other 　
Bite record 　 Working impression tray 　 　 Opppsite impression tray 　 　 Study model
Design Graph: Design requirements(Please describe): 　
　
　 　
　 　 　
　 　 　
　 　 　
　 　 　
　 　 　
　 　 　
　 　 　
　 　 　
　 　 　
　 　 　
　 　 　 　 　 　 　 　 　
Received date 　 Work content Finish date Technician Inspector