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• IMPLANT REMOVABLE Rx • Dr.

Name__________________________________________________ Phone #__________________________

Acct. #_____________________________________ Patient Name_____________________________________


GLIDEWELL First Last

LABORATORIES See Reverse for Working Times


Address/Email_______________________________ Deliver by 5 p.m. on _____________________________
4141 MacArthur Blvd. • Newport Beach, CA 92660
Enclosed with case: ❑ Impressions ❑ Models ❑ Bite ❑ Photos ❑ Other:__________________________________
800-854-7256 • Fax 800-411-9722
* PLEASE COMPLETE THIS SECTION *
❑ Upper ❑ Lower (A-P Spread is 1.5 x A.P) First molar occlusion

Tooth Shade _____________


Implant System________________________
Implant Diameter ________mm
❑ Bite block
❑ Diagnostic setup
❑ Setup try-in
❑ Implant verification jig
❑ Custom tray
DISTANCE BETWEEN ANTERIOR DISTANCE BETWEEN ANTERIOR
❑ Reset AND POSTERIOR IMPLANTS: _____mm AND POSTERIOR IMPLANTS: _____mm
UPPER AP SPREAD X 1.5 mm: _____mm LOWER AP SPREAD X 1.5 mm: _____mm
❑ Final prosthesis
(See reverse for compatible implant systems and limited warranty details) IMPLANT DENTURE APPLIANCE MINI IMPLANTS WITH O-BALL HEAD
(CHOOSE ONE) ❑ Ø2.2 mm ❑ Ø2.5 mm ❑ Ø3.0 mm
❑ BruxZir Solid Zirconia Hybrid Bar Implant Specify quantity of each length:
Prosthesis†
(Premium teeth standard) ___10 mm ___10 mm ___10 mm
❍ Bite splint (Additional fee applies) ___13 mm ___13 mm ___13 mm
___15 mm ___15 mm ___15 mm
❑ Inclusive Screw-Retained Hybrid Denture†
(Premium teeth standard)
PROSTHETIC STENT
❑ Inclusive Locator Bar Overdenture
Tooth # __________________
(Premium teeth standard)
❑ Fully edentulous
❑ Inclusive Locator Overdenture
(Kenson teeth standard) ❑ Acrylic ❑ Vacuum formed
❑ Inclusive Mini Implant Overdenture Pilot Holes: ❑ Yes ❑ No Dia: ________mm
(Kenson teeth standard)

❑ Denture fully edentulous (Kenson teeth standard) Radiographic Markers: ❑ Gutta percha
❑ Barium (20%)
❑ Duplicate denture
DENTURE REINFORCEMENT
Tooth setup: ❑
 Ideal ❑ Characterized ❑ Kenson teeth (Included at no extra charge) ❑ Horseshoe cast palate
❑ Copy study model Shade _____________ Mould _____________
❑ Cast mesh 360° wraparound
❑ Copy existing denture ❑ Premium brand teeth (Extra charge may apply)
Signature_____________________________ ❑ Male ❑ Female Age ________ Shade ______ Brand ______ Mould ______ † Pricedoes not include multi-unit abutments and may
vary when original equipment manufacturer (OEM)
Acrylic shade: ❑ G1 (Standard) ❑ Name on appliance (Additional charge)
License #_____________________________ __________________________________________
components are requested or required for the chosen
Ethnic: ❑ G3 (Med) ❑ G4 (Dk) implant system. Half of payment is due after first
appointment; half is due at final delivery.
© 2017 Glidewell Laboratories
GL-2285-110617
IMPLANT WORKING TIMES TERMS AND WARRANTY INFORMATION

Please allow full working time for each product selected. Working Only $7 shipping per box each way (contiguous U.S. only;
times are NOT guaranteed and do NOT include weekends or holidays. shipping charge varies for Alaska, Hawaii and Puerto Rico).

 Days in Lab
BruxZir Hybrid Bar Implant Prosthesis All Restorations Made in the USA
Bite block������������������������������������������������������������������������������������3
Wax setup reset/implant verification jig��������������������������������������4 We honor VISA, MASTERCARD, AMEX and DISCOVER.
Bite splint.....................................................................................3
TERMS: Cost of collection of any account will be paid by the customer. All accounts are pay-
Final BruxZir prosthesis��������������������������������������������������������������8
able within 30 days of statement date. Accounts not paid within the stated terms will be
Screw-Retained Hybrid Denture 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.
Bite block������������������������������������������������������������������������������������3
Wax setup reset/implant verification jig �������������������������������������4 NO-FAULT REMAKE POLICY: Glidewell Laboratories is pleased to process all remakes or
Wax setup to finish�������������������������������������������������������������������10 adjustments at no additional charge if requested within the warranty period and accompanied
by the return of the original appliance.
Fabricate CAD/CAM titanium framework�����������������������������������7
Final transfer of setup onto titanium framework������������������������5 LIMITED WARRANTY/LIMITATION OF LIABILITY. For warranty terms and conditions and
Process acrylic and denture teeth onto framework�����������������10 limitation of liability, visit glidewelldental.com/policies-and-warranties/.

Locator CAD/CAM Milled Bar Overdenture


THE BRUXZIR® HYBRID BAR IMPLANT PROSTHESIS IS COMPATIBLE
Bite block������������������������������������������������������������������������������������3 WITH THE FOLLOWING IMPLANT SYSTEMS
Wax setup reset/implant verification jig �������������������������������������4 BIOMET 3i™ CAMLOG® DENTSPLY Implants Glidewell Direct HIOSSEN®
Wax setup to finish����������������������������������������������������������������������6 Certain ®
SCREW-LINE ANKYLOS® C/X Hahn™ Tapered Implant System HG System
ASTRA TECH Inclusive® Tapered Implant System
Fabricate CAD/CAM titanium framework and final setup��������12 Implant System®
Process acrylic, denture teeth and Locator attachments����������6 Neoss® Nobel Biocare Straumann® Sweden & Martina Zimmer Dental
Neoss ®
Brånemark System RP ®
Bone Level Premium Screw-Vent®
Locator Implant Overdenture Implant NobelActive® Tissue Level Shelta
System NobelReplace®
Bite block������������������������������������������������������������������������������������3
Wax setup to finish����������������������������������������������������������������������6 INCLUSIVE® CAD/CAM MILLED IMPLANT BARS ARE COMPATIBLE
WITH THE FOLLOWING IMPLANT SYSTEMS
Wax setup reset��������������������������������������������������������������������������4
Process final denture including Locator processing caps���������6 BIOMET 3i™ CAMLOG® DENTSPLY Implants Glidewell Direct HIOSSEN®
Certain® SCREW-LINE ANKYLOS® C/X Hahn™ Tapered Implant System HG System
External Hex ASTRA TECH Inclusive® Tapered Implant System
(4.1mm) Implant System®
All Restorations Keystone Dental Neoss® Nobel Biocare Straumann® Sweden & Martina Zimmer Dental
Made in the USA PrimaConnex® Neoss® Brånemark Bone Level Premium Screw-Vent®
Implant System® RP Tissue Level Shelta
System NobelActive®
NobelReplace®
All rush cases must be prescheduled by calling
Inclusive is a registered trademark of Prismatik Dentalcraft, Inc. Hahn Tapered Implant is a trademark of Prismatik Dentalcraft, Inc.
800-944-7874 before the case is shipped. All other trademarks are property of their respective owners.
Time of pickup and delivery may affect turnaround time. Glidewell Laboratories works in partnership with Keystone Dental, Neoss and Sweden & Martina.

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