RX Form | iyds

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I & Y Dental Studio

Servicing Northeast Ohio Since 1983

440-248-8188

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Online Rx Form for Dental Professionals

Date picker

DDS First name*

DDS Last name*

Return Date*

Patient's Name*

Patient's Age

Shade*

Phone*

Gender

Male

Female

Stump Shade

Instructions/Notes*

Restoration*

Zirconia

E-MAX

Zirconia Lingual with Porcelain Facial (PFZ)

Full Cast Metal

Porcelain fused Metal (PFM)

PMMA

Porcelain Surface

Smooth

Moderate

Heavy

Alloy

Gold

Nobel

Porcelain Surface

Included with Case

Study Models

Opposing Models

Stick Bite

Models of Temps

Photos

Blue Bites

Articulator

Shade Tab

Nothing

Implant Abutment Material

Titanium

Nitride Titanium (Gold)

Zirconia

File upload

Address

DDS License Number

Signature*

I & Y Dental Studio

iydental@iydentalstudio.com

6567–A Cochran Road
Solon, Ohio 44139

Phone: (440) 248-8188
Fax: (440) 248-8825

Web Site by SSG Web Services

Hours of Operation
Monday — Friday
9:00am — 4:00pm

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