Order Form
BITE TH office used only
BITE Dental (Thailand) Company Limited
Dentist :
Order Date :
Patient :
Return Date :
Gender :
Age :
Time :
Work Type
Fixed Work
Removable
Porcelain Fused to Metal (PFM)
Full Metal Crown (FMC)/inlay/onlay
Maryland Bridge
Implant (most common systems)
SENT NECESSARY ABUTMENTS
Stift crown
Post & Core
Inlay/Onlay
Telescompic
Empress II-crown
crown/inlay/onlay/veneer
Zirconium oxide Green (AIIZirkon)
Zirconium oxide HIP (AIIZirkon)
Partial Frame (only metal)
Partial Frame with elements
Acrylic Denture
Full Denture
Vitaflex
Orthodontics
Nightguard
Sportguard/Mouthguard
Others
No Units:
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
Metal Design
PONTICS:
METAL COPING LINGUAL:
Alloy
Non Precious
Semi Precious
Yellow
White
High Precious
Yellow
White
Shade
Translucent
Vita/Biodent/Ivoclar/Others
Shade
Cervical
colouring
FISSUR STAINING: (SURFACE)
No
Light
Medium
Heavy
OCCLUSAL STAINING:
No
Light
Medium
Heavy
Margin Design
No Metal Margin
Buccal Metal Margin
Lingual Metal Margin
Buccal/Lingual Metal Margin
3/4 Occlusal Metal
Occlusal Metal
Mesial / distal
Porcelain Margin (Only if shoulder prepared)
INSTRUCTIONS:
Enclosed
Working Model
Study Model
Shade
Tray
Bite
Others
Die
Articulator
Others
520 Floor 5,6 soi Ratchadapisek 26, Ratchadapisek Road, Samsennok, Huay-Kwang, Bangkok 10320 Thailand
Tel: +662 541-4541, www.bite-thailand.com, Email: info@bite-thailand.com
