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Practice Information
Company (Practice) Name
Company (Practice) Legal Name (if different)
Parent Company (Optional)
Practice NPI II Number
(If not available, click on
NPPES NPI Registry
):
Practice Code (Office Location # / Epicore ID)
Practice Email Address
Practice Phone Number
Practice Addresses
Street Address
Address Line 2
City
State / Province / Region
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Afghanistan
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Country
Billing Information
Name
First
Last
Email
Phone
Payment preferences
Auto-Pay
Online-Pay
Check
Call For Payment
Other
Special instructions: (i.e. group consolidated statement, invoice frequency)
Customer Type
DSO Name (if applicable)
GPO Name (if applicable)
Customer Class (Speciality)
General Dentistry
Pediatric Dentistry
Orthodontics
Endodontic
Prosthodontics
Other
Fee Schedule
DSO
Default
Special Pricing
Shipping Carrier
UPS
Fedex
Driver
Additional Instructions for account set-up
Dentist Information
Name
First
Last
NPI I Number (Dentist)
(If not available, click on
NPPES NPI Registry
):
License #
Dentist Preferred Method of Communication
Text
Call
Email
Dentist Email Address
Dentist Email Phone
Does dentist practice at multiple locations?
Yes
No
Other Locations
Address
Zip
Dentist NPI II
Add
Remove
Dentist Specialty
General Dentistry
Pediatric Dentistry
Orthodontics
Endodontic
Prosthodontics
Other
Fixed Preferences
Preferred Posterior Crown
Full Contour ZR (Default)
Translucent ZR/Picasso
Layered ZR
Emax Crown
PFM (Porcelain fused to metal)
Full Cast Crown
PFM (Porcelain fused to metal)
Base metal (Default)
Semi-Precious
HN gold metal (White/Yellow)
Full Cast Crown
Base Metal
Semi precious Yellow (Default)
HN Gold Metal (White / Yellow)
Preferred Anterior Crown
Translucent ZR / Picasso (Default)
Layered Translucent ZR / Layered Picasso
EMax
PFM (Porcelain fused to metal)
Other
PFM (Porcelain fused to metal)
Base metal (Default)
Semi-Precious
HN gold metal (White/Yellow)
Occlussion
Out of Occlusion -0.3mm (Default)
Point Contact -0.05mm
Slightly High +0.05mm
Way out of Occlusion -0.5mm
Custom Value
Add a custom value
Interproximal Contacts
Normal/Passive fit (Default)
Broad/Wide/Snug contacts
Anatomy of teeth
Match Adjacent anatomy (Default)
Idealized (High detail)
Basic/Minimal Anatomy
Occlusal Staining
None (Default)
Light (Pit & Fissure)
Pontic Design
Modified Ridge Lap (Default)
Sanitary (No Contact)
Full Ridge Lap
Ovate
Point/Light Contact
Insufficient Occlusal Space
Trim Opposing (Default)
Trim Prep and supply reduction coping
Contact doctor on each case
Unclear Margins
Call Office (Default)
Email office with scan images (digital only)
Return for Dr. to Trim
Proceed as best possible
Preferred Articulation Method
Printed Articulator (Default)
Basic Metal Hinge
Semi Adjustable
Email
Semi Adjustable
Artex
Denar
Kavo
Panadent
Implant Preferences
Preferred Restoration Style
Screw Retained (Default)
Cemented
Please follow RX
Crown Material
Full Contour ZR (Default)
Translucent ZR/Picasso
Layered ZR/PFZ
eMax
PFM
Preferred Components
Leixir Branded (Preat, DESS or similar) (Default)
OEM Components (Request on RX)
Anodize (Gold or Pink coloration) components?
Yes (Default)
No
Create Placement Jig for Custom Abutment seating in mouth?
Yes
No (Default)
Anterior Margin Depths
Buccal
Interproximal
Lingual/Palatal
Posterior Margin Depths
Buccal
Interproximal
Lingual/Palatal
If Screw Access hole is Visible on Buccal/Facial
Convert to Angled Screw Channel (Default)
Convert to Cement Retained
Proceed with Restoration
Please contact office to discuss
Email
Phone
Design Approvals Required
No (Default)
All Cases
When Requested on RX
Preferred Attachments for Overdentures
Locator products (Default)
Equator Attachment
Please call to treatment plan cases
Other
Removable Preferences
Full Dentures
Default Denture Style
Standard – basic anatomy and tooth mould (Default)
Premium – IPN /Ivoclar moulds, anatomic festooning and finishing
Elite – Highest level of detail. Stippling, rugae, anatomic design, balanced or lingualized occlusion
Post-Dam Upper Dentures
Yes (Default)
No (Digital Denture option only)
Denture Material
Printed (Default)
Acrylic
Occlusal Schemes
Centric (MI) (Default)
Lingualized
Balanced
Partial Dentures
Default Cast Partial Denture Style
Standard – CoCr alloy framework, traditional acrylic and carded teeth (Default)
Premium/Digital – Wironium Laser sintered framework for superior longevity, Lucitone base, IPN teeth
Partial frame design
Please design ideally (Default)
Follow my drawn designs
All Acrylic Partials Preferred clasping
Wrought Wire (Default)
I-Bar
Roach arm
Follow RX for all
Nightguard/Mouthguard
Preferred Arch for Nightguards
Lower (Default)
Upper
Preferred Occlusion for NightGuards
Group Function, Point contacts in Centric (Default)
Cuspid Rise, Point contacts in Centric
Other
Preferred Arch for Mouthguards (Athletic)
Upper (Default)
Lower
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