Online RX Form – INFINITY DIGILAB LLC

Doctor’s Name *

Patient *

Last Name *

Email *

Phone *

Today’s Date *

Due date by 5:00 p.m. on *

IMPLANT INFORMATION

Note: Please send a patient approved study model on all work involving anterior teeth

SHADE *

STUMP *

Occlusal Staining:

Medium *

None *

Light *

Dark *

PONTIC DESIGN *

Sanitary Pontic
Ridge Lap
Modified Ridge Lap
No Contact

ADDITIONAL INSTRUCTIONS

Licence # *

Signature

Website

INFINITY DIGILAB LLC
10899 Montgomery Blvd. NE, Suite C
Albuquerque, NM 87111
Phone: (505) 292-9880
info@infinitydigilab.com
www.infinitydigilab.com
After Hours: (505) 401-0802