UNIVERSAL Rx | 888-405-1238 • Fax 630-955-2020 • LSK121.com
940 E. Diehl Rd., Naperville, IL 60563
Dr. Name
Phone
Address
E-mail
Patient Name
Sex
ALL CERAMICS
M / F
DATE SENT
/
/
DATE DUE
/
/
AGE
PLEASE SEND
Enclosed with case:  Impressions  Models  Bite  Photos  Other: ___________________________
e.max
Posterior
Anterior
 Monolithic e.max
 IPS e.max Layered
Zirconia
 Kosmic Press Layered
CASE INSTRUCTIONS:
8
7
9
10
11
6
Posterior
 OccluZir(Full Contoured)
 Zirconia Layered
 Natural Posterior
12
5
Anterior
 Monet Pure Zirconia Layered
 C&B Rx
 LSKselect Rx
 Mailing Labels
 Case Boxes
 Bio Bags
4
(only the facial and occlusal surfaces are cut back and layered with porcelain)
RIDGE RELIEF
13
3
14
UPPER
15
2
Veneers  Hollywood Veneers  No/Minimal Prep Veneers
 Feldspathic  Pressed
1
16
Ceramic Composite  GC Gradia  Fiber Reinforced
R
PFMs
17
31
18
LOWER
19
30
20
29
 Lingual metal band  360° metal band  Extra thin
 Eco3 - Non Precious  Semi Precious  White Precious
(180º Porcelain Butt Margin and up to 1 dwt alloy included)
28
21
27
22
26
FULL-CAST RESTORATIONS
25
24
23
RETURN FOR
 Individual units  Cement-on Implant
 Screw-retained Implant  Splinted
Screw-Retained Implant Integrated Package™
 PFM Screw-Retained Crown
 OccluZir Screw-Retained Implant Crown
Cement-Retained Implant Integrated Package™
 Ti Abutment+PFM Crown  Ti Abutment+Zr Crown
 Zr Abutment+e.max Layered Crown
 Zr Abutment+Zr Layered Crown  Zr Abutment+OccluZir
 Metal occlusion
 Metal island
 Reduce opposing
 Reduction coping
 Call doctor
 ________________
 Cusp to fossa
 Light open  Open
RESILIENT LONG-TERM PROVISIONALS
IMPLANT INTEGRATED PACKAGES
IF NO OCCLUSAL
CLEARANCE
OCCLUSAL CONTACT
 75% Yellow Gold Noble  50% Yellow Gold Noble
 Noble Silver Metal  Non Precious Silver Metal
Abutment #s_____________________________________________
Pontic #(s)____________________________ Total units_________
Reinforcement:  None  Wire  Fiber  Metal
Amount of prep reduction:  1 mm  2 mm
PONTIC DESIGN
L
32
 Non Precious (Base)  Semi Precious (Noble)
 White Precious (High Noble)  Yellow Precious
 Titan (using Titanium alloy, ADA code: D2794)
Marginal Design:  No metal showing  Porcelain butt
 None  Light
 Medium  Heavy
 Die Trim
 Metal Try-In
 Bisque Try-In
 Finish
 Chairside Shade Guide™
Color Communication  Other Shade System:
Final Shade
Stump Shade
 Photos attached  e-mail to: [email protected]
 Custom Shade - Call to schedule.
DR’S SIGNATURE
LICENSE#
(Personal signature of doctor in compliance with the Illinois Practice Act) Dentist agrees to company policies as stated on reverse.
FULL ARCH IMPLANTS
FULL DENTURES
PARTIAL DENTURES
NIGHT GUARDS/SPLINTS/TMJ APPLIANCES
Screw-Retained Full Arch Implant
 Hybrid Ceramic Restoration  CAD/CAM Zirconium Restoration
Cement-Retained Full Arch Implant
 _______Abutment  __________________Restoration
 All-on-4 Screw-Retained Hybrid Denture
 LSK Deluxe Denture
 Overdenture w/attachments  Cast Strength  Mesh Strength
 Attachment Bar Overdenture  Hader  Locator  ERA
 Other: _________________________________________
Check List
 Metal Free
 Fiberflex™  DurAcetal®  Flipper  Essix®
Choose Arch:
 Metal Cast Frame
Clasps: Metal  Cast  Wrought Wire
Flexible  Clear  Tooth Colored  Tissue (Pink)
 Occlu-Protect (Clear hard acrylic)
 Occlu-Ease (Clear hard/soft acrylic)
 Occlu-Soft (Clear pliable acrylic)
 Occlu-Ever (Clear thermoplastic resin)
 Occlu-Flex (Biocryl)  Occlu-Snug (Biocryl)
 Occlu-Dual (Biocryl)  Occlu-Balance (Clear hard acrylic)
 Surgical Clear Stent (Biocryl)
 Myerson EMA Sleep Apnea Device
 Muscle Deprogramming Device
 Other:________________________________________________
(More details on Full Mouth Implant Rx)
KALEIDOSCOPE WAX-UP
 Kaleidoscope Wax-up
 Esthetic Wax-up  Bite Correction  Implant Wax-up
 Additional Request
 Pink Wax  Mock-up  Study Model Duplication
 Prep Guide Model  Stent for Temporary  Putty Matrix Guide
 Mount w/Bite Correction __CR __CO  _____________ Articulation
 Midline-Marked  High Lip Line-Marked  Proper Lip Support
Shade:
Mould:
Tissue:
Finish:
Palate:
Anterior __________
Posterior __________
Anterior __________
Posterior __________
Shade __________
 Smooth  Characterized
 Smooth  Rugae
 Custom Tray  Wax Rim  Wax Setup Try-in  Finish
 Frame Only  Frame w/Rim  Frame w/Teeth Try-in
 Frame w/Teeth Finish
RELINE/REPAIR FULL DENTURE or PARTIAL
 Reline  Repair  Rebase  Add Metal Reinforcement
 Upper  Lower
Choose Design:
 Anterior guidance  Flat plane  Canine rise
(More details on LSK121 Splint/Night Guard Rx)
© 2014 LSK121 Oral Prosthetics
LAB USE ONLY
PAN NUMBER
CASE NUMBER
RECEIVED BY
Full
Quadrant
Triple
Opposing Model
Study Model
Working Model
Bite
Denar Articlulator
X-ray
Photo
Memory Card
CD
Partial
Original Pinned
Original Study
Original Impression
Crown
Articulator Box
Impression Coping
Implant Screw
Lab Analog
Jig
Abutment
Bite Block
Solid Wax
Titanium Bar
Post Core
Locators
Face Bow
Metal Articulator
Attachments
AGREEMENT
These Terms and Conditions are made effective by the customer set forth on the reverse hereof (“Dentist”)
submitting this form (“Agreement”) to LSK121 Oral Prosthetics, an Illinois Corporation (“LSK121”). The
(“Dentist”) agrees to a contract for the sale and delivery of the specially fabricated goods mentioned herein
(“Goods”).
1. Dentist agrees to pay in full the stated price of Goods within 30 days after the date of the statement. All
balances remaining past such date will incur a 2% late service charge. Accounts not paid within the stated
terms will be subject to C.O.D. status.
2. Any and all attachments, including but not limited to, prescriptions, modifications, diagrams, photographs,
models or instructions of any sort, will be incorporated into this Agreement, unless LSK121 objects. Should
the Dentist cancel any order submitted before shipment, the Dentist shall pay for any loss or damage to
LSK121.
3. Dentist must completely clean all blood and saliva from all materials used in the mouth, and must disinfect
all of these items before sending them to LSK121 and again when returned from LSK121 before placement
in patient’s mouth.
IN LAB WORKING TIMES
Times shown do not include transit time, the day case is received or shipped, Saturdays, Sundays, or Holidays.
RESTORATIONS
WORKING DAYS
Monolithic e.max | OccluZir | Ceramic Composites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
e.max Layered | Natural Posterior | Zirconia Layered | Veneers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
PFMs | Full-Cast Restorations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Provisionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Implant Veritication Jig . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Custom Abutment Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Custom Bite Rims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Implant Integrated Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Custom Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Bite Rims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Set-up for try-in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Re-set for try-in using same teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Re-set for try-in needing new teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Finish full denture from wax try-in stage (no changes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Finish full denture with changes or as an immediate from wax try-in stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Finish partial denture from wax try-in stage (no changes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Finish Partial Denture from wax try-in stage with changes needed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hard bite splints or Implant stents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Resilient Long-term Provisional™ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Partial Framework (metal work only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Rebase (full denture) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Soft Liner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Soft Mouth Guards Or Bleaching Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Flipper (simple) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Attachment or Implant work . . . . . . . please call, it will be determined by the type of case and its complexity.
Repair (simple) . . . . . . . . . . . . . . . . . . available to be pick up here same day at 5:00 pm if it is ready in our office by 9:30 am
otherwise 24 hrs in lab.
Reline (simple) or Add-on (simple) . . done same day by 5:00 pm if it is ready in our office by 9:30 am and has been
scheduled ahead of time with the lab and given a reference number otherwise
minimum of 24 hrs in lab.
RUSH CASES MUST BE PRE-SCHEDULED
3 DAYS/2 DAYS/1 DAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .additional charge | call for fee
TO PRE-SCHEDULE RUSH CASES, CALL
1-888-405-1238
4. The Dentist has the right to inspect Goods prior to acceptance. If Goods are not returned to LSK121 within
10 business days, this will mean acceptance of Goods. Other forms of acceptance shall include, but are not
limited to, cementing of Goods in the mouth, requesting shade changes or modification of preparations,
bites or designs. There will be absolutely no returns or refunds after 30 days from the date of receipt of
finished Goods by the Dentist.
5. Should the Dentist request a remake of Goods, Dentist agrees to resubmit all original Goods including, but
not limited to, original impressions, models and restorations to LSK121. LSK121 must have original Goods
to evaluate possible restoration replacement or repair, the cost to Dentist, and to determine if original Goods
are repairable or require remake of Goods. If any portion of the Goods, including materials, is not returned
to LSK121, the full stated price of Goods will be due to LSK121.
6. Should Dentist return nonconforming Goods and such nonconformance is the fault of the Dentist, Dentist
must give LSK121 the opportunity to provide conforming Goods within a reasonable time and bear the
burden of all related costs, including, but not limited to, the costs of Goods and shipment. Should Dentist
return nonconforming Goods and such nonconformance is the fault of LSK121, Dentist must give LSK121
the opportunity to provide conforming Goods within a reasonable time at the original stated price. Should
Dentist return nonconforming Goods and the nonconformance is the fault of both Dentist and LSK121, or
fault is difficult to determine, Dentist must give LSK121 the opportunity to provide conforming Goods within
a reasonable time and the costs of remaking or replacing Goods and all related expenses and shipping
costs are to be divided in proportion. LSK121 shall determine allocation. LSK121 shall also determine
whether Goods conform.
7. Should LSK121 fail to provide conforming Goods in a reasonable time, Dentist’s options are limited to the
return of the goods and repayment of the stated price, or to repair and replacement of nonconforming
Goods by LSK121.
8. If Dentist chooses to use his/her own Rx (prescription) form, or the form of another lab or organization, the
terms set forth in this official LSK121 Rx will govern the contract for all products and specially fabricated
Goods.
9. The parties to this Agreement shall be governed by and the Agreement shall be construed in accordance
with the laws of the United States and the State of Illinois without giving effect to the conflicts of laws
provisions thereof. The parties further agree that any and all actions that may arise under this Agreement
shall lie exclusively in the Courts of the United States in the State of Illinois located in the County of DuPage,
State of Illinois.
10. If any terms of this Agreement are held by a court of competent jurisdiction to be invalid or unenforceable,
then this Agreement, including all of the remaining terms, will remain in full force and effect as if such invalid
or unenforceable terms had never been included.
11. The Dentist agrees to pay all late service charges, legal and collection costs in the event of non-payment or
suit, including reasonable attorney fees.
12. The Dentist agrees to sign an official LSK121 Oral Prosthetics laboratory slip, which includes his License
Number, to be kept on file with the aforementioned laboratory. This will serve as “Permission Granted” for all
work to be completed in the future, regardless of which generic, digital or other lab’s prescription slip the
Dentist chooses to use for his case work.
© 2014 LSK121 Oral Prosthetics