Excel Dental Lab 800/61-62 Soi Trakulsuk, Asoke-Dindaeng Rd., Dindaeng, Bangkok 10400 Thailand Tel: +662 2463704 Fax: +662 2465669 www.excel-dental.com  e-mail: contact@excel-dental.com
Remember to include: Rx form, Impression, Opposite model and Wax bite.
 Send Date : ___ /___ /____
   Due Date :  ___ /___ /____
 Clinic : _______________ 
 Dentist : _______________
 Patient : _____________ Ref :________
   Male   Female   Age : _______

CROWN   BRIDGE 
 Porcelain Fused to Metal #______
Full Metal #______
In-Ceram #______
IPS e.max #______
Procera #______
Cercon #______
Zeno #______ 
Empress Esthetic Inlay/Onlay #______
Empress Esthetic Veneer #______
Maryland Bridge #______
Composite #______
Inlay/Onlay #______ 
Veneer #______
Post & Core #______ 
Telescopic #______ 
Temporary #______
Implant Service #______
Cast Partial Frame #______
Acrylic Denture #______
Other __________________
 

SHADE:_______________ 

New Case
Try-in
Rush Case		 Lab Adjust
Lab Remake
(Required old impression work)

ENCLOSED WITH CASE
Impression 
Bite  
Working Model		 Study Model
Old Prosthesis
____________

METAL
Non-Precious  
Palladium Base
Semi-Precious 52%
Precious 86%		 Gold
White Gold
____________
MARGIN DESIGN
 Metal_____ mm
Porcelain Margin_____mm (Only w shoulder prep.)
  Full porcelain
360 metal margin
Lingual metal mar.		 3/4 metal occulus.
Full metal occulus.
Metal fissures

ANTERIOR
Full porcelain
Lingual metal mar.		 3/4 lingual metal
Full lingual metal

PONTIC DESIGN

STAINING
None     Light      Medium   Dark

 Occlusal        Gingival

ADDITIONAL INSTRUCTION
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