New Account Form - Leixir Dental Laboratory Group

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New Account Form

1Account Information

2Fixed Preferences

3Implant Preferences

4Removable Preferences

Practice Information

Company (Practice) Name(Required)

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(Required)

Practice Phone Number(Required)

Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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)(Required)

GPO Name (if applicable)

Customer Class (Speciality)

General Dentistry

Pediatric Dentistry

Orthodontics

Endodontic

Prosthodontics

Other

Fee Schedule

DSO

Default

Special Pricing

Additional Instructions for account set-up

Dentist Information

Name(Required)

First Last

NPI I Number (Dentist)(Required)

(If not available, click on NPPES NPI Registry):

License #

Dentist Preferred Method of Communication(Required)

Text

Call

Email

Dentist Email Address(Required)

Dentist Phone(Required)

Does dentist practice at multiple locations?

Yes

No

Other Locations

Address

Zip

Practice NPI II Number

Dentist Specialty

General Dentistry

Pediatric Dentistry

Orthodontics

Endodontic

Prosthodontics

Other

Dentist Trial Success Criteria

Why did dentist select Leixir?

How many cases does dentist intend to send to Leixir in next 2 months to assess satisfaction?

Fixed Cases

Implant Cases

Removable Cases

How will dentist measure success (i.e. specific expectations on quality, fit, turnaround time, communications, etc.)?

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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Leixir Dental Laboratory Group

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Blue Box
Comprehensive Aesthetics Center (C.A.C.)
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Leixir New York
Precision Craft Dental Laboratory
Thompson Suburban Dental Laboratory
York Dental Laboratory, Inc.

Our Labs

3659 Tampa Rd.
Oldsmar, FL 34677
1-888-991-7255

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