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DIAGNOSTIC - WAX - Up Check List

This document is a diagnostic workup form for a dental case. It provides information about the patient such as age, gender, and desired changes to tooth length or shade. It also specifies the clinical goals, materials to be used, proposed dental designs such as crowns or veneers, and items to be sent to the lab like impressions or photos. The last section outlines payment terms including balances due within 30 days and fees for late payments.

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RAED
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40 views

DIAGNOSTIC - WAX - Up Check List

This document is a diagnostic workup form for a dental case. It provides information about the patient such as age, gender, and desired changes to tooth length or shade. It also specifies the clinical goals, materials to be used, proposed dental designs such as crowns or veneers, and items to be sent to the lab like impressions or photos. The last section outlines payment terms including balances due within 30 days and fees for late payments.

Uploaded by

RAED
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Pan# Desire shade change to:

Dr#

Date:
DIAGNOSTIC WORK UP
Doctor Request Return Date
Address E-mail
City State Zip Phone Length Desire from Margin: Centrals mm Laterals mm Canines mm

Patient M/F Age Smile Design Guide Used Style


Surface texture desire: Smooth Light Medium Heavy
Clinical Goal of Case Functionally Driven Aesthetically Driven
Close Diastema Lengthen Teeth Shorten Teeth Establish Function
Corridor Expansion Move Midline___ mm Change Midline Cant Change Incisal Cant

VDO Changes: = Add ______ mm Decrease ______ mm OK to relieve opposing: YES NO

Materials Selections: Preferred Method of Communication: Phone E-mail Zoom Facetime

Wax Up Additive Only Digital Dx No Kit Additional Information:


Wax Up Kit Digital Dx Design Only Digital Dx Kit

Design:
Crown Design Teeth #
Veneer Design Teeth #
Min Prep Veneer Teeth #
Bridge or Future Extraction Teeth # Pontic Design
Future Implant Sites:
Adjust Gingiva, Crown Lengthening mm

Articulator:
Brand Facebow: Facebow follows interpupillary line Other:

Items to Send :
Upper and Lower impression, models or Intraoral scan
CR bite (after Deprogrammers), MIP Bite
FaceBow
3 Photos - Lip in Repose ( say Emma), Open Mouth smile (say Sea) and Full Smile.

Terms: Balances not paid within 30 days of statement are subjected to a delinquency charge. Accounts that
become 45 days past due will be placed on C.O.D., and a portion of the remaining balance will be
added to each case deliverd thereater. The dentist will be responsible for all collection cost including
attorney’s fees incurred in th event that accopunt collection becomes necessary.

Dentist’s Signature
License # Date
For General Restorative Rx go to www.golddustdental.com or submit online go to
Gold Dust Dental, Inc. 2242 S. McClintock, Suite 1 Tempe, Arizona 85282 www.golddustdental.com and select Client Services.
(480) 968-6131 1-800-513-6131 FAX (480) 968-8831 EMAIL: [email protected] LABORATORY COPY

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