$449 Ti - $499 Zr RESTORATIVELab PACKAGE 10 Business Days In

INCLUDES: Titanium or Zirconia abutment*, final screw, lab screw, lab analog, soft tissue model, shipping and handling of parts and final restoration. DOCTOR ADDRESS CITY PHONE EMAIL STATE FAX ZIP PATIENT NAME AGE MALE/FEMALE

Blending Nature, Art and Technology

TODAYS DATE
*Applies only for: Astra Branemark Biomet 3i Internal Biomet 3i External Keystone PrimaConnex 3.0, 3.5/4.0, 4.5/5.0 NP, RP, WP 3.4, 4.1, 5.0, 6.0 3.75, 5.0 3.5, 4.0, 4.5, 5.0 5.5

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DUE DATE

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3.5, 4.0, 5.0, 5.5 NP, RP, WP, 6.0 NP, RP 3.5, 4.5, 5.7

Neoss NobelReplace NobelActive Zimmer Screw-Vent

MARGINAL PLACEMENT

Tooth #

Implant Type

Diameters

Buccal/ Lingual Mesial Facial

Distal

Abutment Selection

Titanium

Zirconia Restorations Shade Emergence Width

No Tissue Displacement (Default) Tissue Displacement Surgical Placement

Zirconium PFM Temporary CAD

($65 extra) ($149)

e.max

(alloy surcharge may be applied)

Semi Precious Screw Retained

($149)

Over Temporary Abutement

Instructions:

DOCTORS SIGNATURE

460 West Larch Road, Suite #1 Tracy, Ca 95304 Toll Free: (877) 325-5873 Fax: (209) 221-6792 contact@alluredentalstudio.com

LICENSE NUMBER