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4041 Dover Road
Youngstown, OH 44511
(330) 782-1824
877-576-9254

Dental Laboratory Work
Authorization

From:
Dr. __________________________________ Phone: ________________________
Address: ____________________________________________________________
Patient________________________________ Date__________________________
Age:______ Sex: ____
Personality: Vigorous Med Delicate

Type of Restoration:

Metal Free Belle Glass Porcelain Jacket Vitapress Veneer Inlay Onlay

Belle Glass To Metal High Noble Noble Porcelain to Metal Porcelain to High Noble Porcelain to Noble Full Cast High Noble Noble White Noble Yellow