Denture Rescue Rx Form Complete the Rx repair form below and then click submit. Thank you! Denture Rescue Rx Form "*" indicates required fields Date* MM slash DD slash YYYY Rx Notes Patient Name* First Last Is this a remake? No Yes PartialsPartial (Select Arch)SelectUpperLowerBoth Upper and LowerPartial TypeSelect1. VisiClear Frame Setup w/ Teeth2. VisiClear Frame w/ Teeth Finish3. Metal frame Setup w/ Teeth4. Metal Frame w/ Teeth Finish5. Acrylic Partial Setup w/ Teeth6. Acrylic Partial w/ Teeth Finish7. Flexible Partial Finish8. Flexible Partial Setup w/ TeethPartial ShadeSelect12345678910DenturesDenture (Select Arch)SelectUpperLowerBoth Upper and LowerDenture ProductSelect1. Bite block upper2. Bite block lower3. Bite block upper and lower4. Setup for tryin5. Process and Finish6. Custom TrayDenture ShadeSelect12345678910Case Type (pickup or drop off or UPS)*Select OneCase is already at lab. (no delivery needed)Patient will drop off the case.A pickup needs to be scheduled.UPS label needs to be sentNotes for delivery service. If there is a specific day other than today, please note it here, otherwise the delivery service will schedule the first available pickup with the client.Dental Lab*Mabel Dental 891 Graham Rd Ste C, Cuyahoga Falls, OH 44221 (877) 622-3533Greater Cincinnati Dental Lab 3719 Struble Rd, Cincinnati, OH 45251 (513) 385-4222Don's Lab 2804 Johnstown Rd Suite B, Columbus, OH 43219 614-804-6896Moskey Dental Lab 2111 East 36th Street Cleveland, OH 44115 (216) 881-2800Dental Associates Lab 3318 Successful Way Dayton, OH 45414 (937) 233-7898(not same day) Artistic Dental Lab Poland West Plaza, 1714 Boardman-Poland Road Poland, Suite 5, Youngstown, OH 44514 (330) 271-9831Lark Labratories 6421 Hamilton Dr E, Holland, OH 43528OtherNotes to LabDentist Name* First Last Signature*Patient Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Apartment or Suite Number Patient PhonePatient Email Dentist Email* We will send you a copy of the Rx.Dentist License* Requested Repair Glue Removal Stainless Steel Mesh Reinforcement Cleaning Reline Fracture Replace/Repair Teeth Add Teeth Model for Duplicate Duplicate Denture Duplicate Partial Miscellaneous HiddenDentist CodeN/ASam SneadTiger WoodsJack NicklausUnique Case ID Δ
