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This form has been created to aid us in working as a team to create an ideal functional and
esthetic diagnostic blueprint for this patient.
RESTORATION TYPE
Total # of teeth to be restored ________________________________tooth #s ____________
Veneers____________________________________________________________
Onlay Veneers_______________________________________________________
Crowns ____________________________________________________________
Onlays_____________________________________________________________
Implants____________________________________________________________
Bridge _____________________________________________________________
Other ______________________________________________________________
SQUARE ROUND
TRIANGULAR
Comments __________________________________________________________________
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___________________________________________________________________________
Comments __________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Comments __________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Comments __________________________________________________________________
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___________________________________________________________________________
Comments __________________________________________________________________
___________________________________________________________________________
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Anterior Guidance
same_______________________________________________________________
steeper______________________________________________________________
flatter_______________________________________________________________
cuspid rise___________________________________________________________
anterior group function - which teeth ______________________________________
other _______________________________________________________________
Comments __________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Please note: Please provide a high quality duplicate model of the wax-up in high quality vacuum-
mixed die stone. We do not require a stent or putty matrix of this duplicate model.