Digital RX – Denture & Partial

Complete this online denture & partial prescription and we’ll generate a PDF that mirrors the Patriot Dental Lab paper RX.

Date Sent

Due Date

Appt. Time

Doctor & Patient Info

Dr.

License #

Account #

Patient Name

Date Prepared

Signature

Instructions

Call Me

Tooth Information

Economy Teeth (Vita MFT) Premium Teeth (Tribos)

Tooth Shade / Guide / Mold

Other

Full Denture

Custom Tray Baseplate & Wax Rim Wax Try-In Process / Finish Immediate

Nature-CRYL Acrylic Shade

Metal Partial Denture

Show clasping on diagram (attach diagram or describe below).

Cast Framework Try-In Framework Only Wax Try-In Process / Finish

TCS Flexible Partial – Tissue Shade

TCS 1 TCS 2 TCS 3 TCS 4

Case Photos

You can select multiple JPG/PNG images. They will be added to the end of the RX PDF and scaled to fit.

Design

Denture & Partial Prescription

Denture Partial Bite Block Crown

Tooth Form

Supplies & Mailing Labels

Prescriptions Boxes Pre-paid UPS Labels Pre-paid Mail Labels

Night Guards / Bite Splints

Repair / Reline / Reinforcement

Email a copy of this RX to rx@patriotdentallab.com