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CITY__________________________________________ STATE____________ ZIP ______________________________

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instructionsPorcelain FuseD to metal

all metal croWn, inlaY/onlaY, Post

all ceramic metal-Free restorations

Premise inDirect comPosite restorations

Dal temPs/raDica long term ProVisionals

Dal natural Full Denture

Vitallium 2000 Plus Partial Denture

imPlant Prosthetics

return Date

l Base Non-Precious l Noble 40% Yellow Goldl Noble White Semi-Precious l High Noble 60% Yellow Goldl Noble SP-Y Yellow Gold l High Noble 75% Yellow Gold

RESTORATIOn IPS E.MAX FULL COnTOUR ZIRCOnIAl Crown l IPS e.max Monolithic CAD l BioZx2l Bridge l IPS e.max Layered Press l BruxZirl Veneer PORCELAIn TO ZIRCOnIA RESIn nAnO CERAMICl Inlay/Onlay l BioZx2 l Lava l Lava Ultimatel Maryland Bridge l DAL EZ

l Inlay/Onlay l Inlay Bridge l Maryland Bridge

ABUTMEnT TOOTH #’S ______________ POnTIC TOOTH #’S ________________

l No Reinforcement l Reinforcement l Cast Metal Frame

l Conventional l Equipoisel Precision/Combination l Saddle-Lock

l Valplast l DuraFlex l FRS l Combination w/Vitallium Subframe

FIXED RESTORATIOn REMOVABLE RESTORATIOnl Porcelain Fused to Metal l Spark Erosionl Captek Nano l IBB-Implant Borne Bridgel All Metal l Overdenture w/Cast Barl IPS e.max l BruxZir l Overdenture w/Attachmentl BioZx2 PFZ l BioZx2 FC l Hybrid Fixed/Detachablel Lava Ultimate Restorative l All on Four

Type of Implant ___________________________________________l Design/Estimate

PATIENT’S NAME ___________________________________________________ / _____________________________(LAST) (FIRST)

PATIENT’S SEX l MALE l FEMALE AGE __________________________________________

PLEASE SEnD: l PRESCRIPTIONS l BOXES l SHIPPING LABELS

DATE ______ /_______ /_______ By 5 P.M.

SHADE NO. _________________________________ l TAB ENCLOSED PREP SHADE_________

l PLEASE CALL ME: DATE ______ /_______ /_______ TIME ______________________________________

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IF THERE IS InSUFFICIEnT ROOMl Reduce and Mark Prep l Fabricate Reduction Copingl Reduce and Mark Opposing l Place Metal Island l Please Call

EnCLOSURES: l Impression l Pre-Op Study Model l Temps Model l Bite Registration l Photo l Shade Diagram

DOCTOR’S SIGNATURE ____________________________________________________________________________

DOCTOR’S LICENSE #_______________________________________________ DATE ______ /_______ /_______

WARRANTY ON BACK

cmfi group PEORIA, IL (309) 692-9191 FORM NO. 109 (05/13)

RESTORATIOnl Porcelain PFMl DALceram LS PFMl Captek Nano PFMl Full Coveragel Metal Occlusall Porcelain Butt Margin

ALLOYl Base Nickel-Free NPl Noble Semi-Preciousl High Noble White Goldl High Noble Yellow Gold

SHADE __________________________ MAkE & MOLD __________________________

l Premium - Portrait IPN or BlueLine Teeth with Premium Finishl Dalecon Value - Kenson Teeth with Fibered Acrylic Finish

l ADDITIONAL INSTRUCTIONS ON BACKl WAX TRY-IN FOR IMMEDIATE EXTRACTION

l DESIGN/ESTIMATE l WAX TRY-IN l BISQUE

l DIE TRIM l METAL TRY-IN l COMPLETE

Dal monoDont briDge

l Acrylic Pontic l Layered Composite Pontic

sPlints/mouthguarDs

FLEXITE MP SUPER CLEAR COMFORT SPLInTS PROFORM MOUTHGUARDSl Super Clear Hard w/Talon l Hard w/Soft l Single Colorl Super Clear Hard l Hard l Multiple Colorsl Soft Talon l Soft l Helmet Strap

snoring/sleeP aPnea

l TAP 3 l Myerson EMAl TAP 3 Elite l Myerson EMA First Step

Flexible metal-Free Partial Denture

All products fabricated in our laboratories located in the USA.

TIME SCHEDULE

Working days do not include Saturdays, Sundays, holidays or days in transit.Please call to make arrangements for emergencies, special requests andprescheduled express cases.

PFM/All-Metal/DAL Monodont Bridge Working Days

All PFM’s ................................................................................................7PFM’s with Attachments ......................................................................10All-Metal Restorations ............................................................................7DAL Monodont Bridge with Resin Tooth ................................................3DAL Monodont Bridge with Composite Pontic ........................................7

All-Ceramic/Composites Working Days

IPS e.max Monolithic CAD ......................................................................6IPS e.max Layered Press ....................................................................10BioZx2 PFZ/DAL EZ ..............................................................................10Lava ......................................................................................................12BioZx2 FC/BruxZir Solid Zirconia ............................................................7Lava Ultimate ..........................................................................................5

DAL Temps/Radica Working Days

DAL Temps or Radica (with or w/o metal reinforcement) ......................7

Partial Dentures Working Days

Vitallium 2000 Plus Frameworks............................................................6All Cast and Precision Frameworks ........................................................8Valplast or DuraFlex Process/Finish ......................................................8Repair Framework ..................................................................................5

Full Dentures Working Days

Custom Trays/Bite Rims..........................................................................3Partial or Denture Setup ........................................................................4Partial or Denture Finish ........................................................................4Soft Liner ................................................................................................3Acrylic Reline/Repair ..............................................................................2Rebase ....................................................................................................3

Preventative Care Working Days

TAP 3/TAP 3 Elite....................................................................................9Myerson EMA..........................................................................................7ProForm Sports Mouthguards................................................................6Flexite MP Super Clear Splints/DAL Comfort Splints ..............................6

Implant Fixed Bridgework Working Days

Porcelain to Metal Crown......................................................................12Full Metal Crown ..................................................................................10

Implant Removables Working Days

Occlusal Rim w/Verification Splint ..........................................................5Model/Clear Stent ..................................................................................5Wax Try-In ..............................................................................................5Cast Bar w/Wax Try-In ............................................................................9Process and Finish ................................................................................5

Spark Erosion Prosthetics Working Days

Primary Bar Casting................................................................................9Secondary Restoration Framework withAttachments and Teeth Set in Wax ..................................................12

Process and Finish ................................................................................6

LOCAL PICk-UP AnD DELIVERY

DAL provides local pick-up and delivery via DAL Delivery Service in specificareas. Please call your local DAL Laboratory to schedule a pick-up.

OVERnIGHT SHIPPInG FOR nOn-LOCAL CUSTOMERS

DAL has contracted with FedEx to provide our customers with guaranteedovernight pick-up and delivery service directly to your office. Call your local DALLaboratory for pre-paid FedEx airbills and inbound shipping instructions orcall FedEx direct at 1-800-463-3339 to schedule a pick-up.

InSTRUCTIOnS

Please insert the cover flap behind the blue copy of the top AuthorizationForm to prevent a carbon impression on the remaining forms. Aftercompletion, detach both the white and blue copies from the booklet. Sendthe white copy (master) to DAL and retain the blue copy (duplicate) foryour patient file.

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COMPLETE DENTALLABORATORY SERVICES

ADDITIOnAL InSTRUCTIOnS:

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BILLInG POLICY

OUR GUARAnTEE

For a period of one full year, Dental Arts Laboratories, Inc. guarantees (1) theworkmanship of new fixed restorations and (2) that all new fixed restorations will fit themaster die or master model if adequate reduction of the prepared tooth was completedaccording to the manufacturer’s recommendations. Failure due to de-bonding (adhesivebonding) is not considered to be the result of inferior workmanship. Failure due toaccident, neglect, abuse, changes in tissue or bone structure, or improper dental hygieneis not covered. This guarantee is extended to a period of five (5) full years for accountsthat are active and in good standing.

What DAL covers:• DAL will refund, replace or repair the defective restoration. All refunds are limited to theamount of invoice. DAL reserves the right to determine if guarantee is applicable.

What DAL does not cover:• Cash refund for work completed• Cost for removal or reinsertion• Cost for incidental or consequential damages, including inconvenience, lost chairtime,transportation costs, lost wages, pain and suffering, or loss of profits

PAYMEnT TERMS

DAL will include an invoice with each case delivered to you. Each invoice is payable withinthirty (30) days. You may pay by this invoice or by the monthly statement that will be sentto you following the last day of the month. Payment is due immediately upon receipt of themonthly statement. The customer agrees to pay each delinquent balance on a monthlyservice charge of 18% per annum (11/2% per month) or the maximum permitted by law.The customer agrees to pay all reasonable attorney fees, collection costs and court costsincurred by DAL and any of its affiliates in enforcing any of these terms and conditions.The customer agrees to these terms and conditions as stated on each printed DALstatement, invoice and work authorization. DAL accepts personal checks, cashier’s checks,Visa, Discover, MasterCard and American Express.

BILLInG qUESTIOnS

For billing questions, please contact your DAL Laboratory Manager.

ILLInOIS DEnTAL PRACTICE REqUIREMEnTSSection 48(a) of the Illinois Dental Practice Act requires a licensed dentist who employs or engages services of person, firm or corporation to construct or repair prosthetic appliance, to furnish a written work order on a form prescribed by Illinois Department of Registration and Education which shall contain: (1) Name andaddress of person, firm or corporation to which work order is directed. (2) Patient’s name or identification number and, if number is used, patient’s name must be written upon duplicate copy retained by dentist. (3) Date on which work order was written. (4) Description of work to be done, including diagrams if necessary.(5) Specification of type and quality of materials to be used. (6) Signature of dentist and number of his license. Dentist and Laboratory must retain their respective copies of work order for three (3) years for inspection at any reasonable time by the Department of Registration and Education or its duly authorized agents.Failure of dentist to comply on any given case is a misdemeanor, and license may be revoked or suspended. Failure of laboratory to comply is a misdemeanor.

Section 48(a)(3) of the Illinois Dental Practice Act provides: “If the person, firm or corporation receiving a written order from a licensed dentist engages another person, firm or corporation (hereinafter referred to as ‘sub-contractor’) to perform some of the services relative to such work order, he or it shall furnish a writtensub-work with respect thereto on forms prescribed by the Department of Registration and Education which shall contain: (a) The name and address of the sub-contractor. (b) A number identifying the sub-work order with the original work order which number shall be endorsed on the work order received from the licenseddentist. (c) The date on which the sub-work order was written. (d) A description of the work to be done by the sub-contractor, including diagrams, if necessary. (e) A specification of the type and quality of materials to be used. (f) The signature of the person, firm or corporation issuing the sub-work order. The sub-contractorshall retain the sub-work order and the issuer thereof shall retain a duplicate copy attached to the work order received from the licensed dentist for inspection by the Department of Registration and Education or its duly authorized agents for a period of three (3) years in both cases.” Failure of Laboratories to comply is amisdemeanor.

IMPRESSION U L TMODEL U L BITE REGISTRATIONARTICULATORCROWN / BRIDGECOPINGVENEERINLAY / ONLAYPOST & COREPARTIAL DENTURE U LMOUTHGUARD U LTRY-IN / BITE RIM U LTRAYS METAL PLASTIC PARTS / ATTACHMENTSSHADE TABPHOTO / DIAGRAMMOUNTING RINGSCD / USB DRIVEOTHER

DAL INTERNAL USE ONLYCASE INVENTORY CHECKLIST

CHECK RECEIVED

#__________

PPD US MAIL

PPD FEDEX

MULTIPLECASES

RECEIVED

OPENED BY:___________

ON:___/___/___