Online RX Form

At Infinity Digilab we are committed to our employees’ health and safety. In the setting of the COVID-19 pandemic, we are hard at work developing strategies to deliver excellent products and services while minimizing our employees to unnecessary exposure within our office. For that reason, we have created an online RX form. We encourage you to use the interactive RX form to submit a digital lab slip. Also Available is a PDF Version for you to Download.

1. Fill out all necessary sections.

2. Press Submit Button.

3. You will see a Thank You Message indicating that your RX Form has been sent to us.

4. We will respond to you with a verification and adn questions on your order.

If you have any questions, please call us at (505) 292-9880.

RX Doctor & Patient Information

***** RX INFORMATION *****

IMPLANT INFORMATION

CUSTOM ABUTMENT DESIGN

ZIRCONIA CAD/CAM

CERAMICS

TYPE OF ANATOMY

FULL CAST

SPLINTS

PARTIAL

TYPE OF OCCLUSION IN CENTRIC

- ENCLOSED WITH CASE -

MISCELLANEOUS

PONTIC DESIGN TYPE

ADDITIONAL INSTRUCTIONS

PLEASE SEND