Please, press PRINT button

         ZEN'S DENTAL LAB
         Full Denture Service
       10804 Highcliff Dr
       Knoxville, TN 37922
       Tel: (865)-966-6084

                            Date _____/_____/____

Dr_________________

Address___________________________
City ____________State _____Zip______
Patient____________________________

Age _______Male ______Female______

Shade_______
Anterior Mould____________
Posterior Mould __________
Type and make of teeth _______________
Denture Material ____________________

         Design Case Above

Date wanted: Occlusal rims___________     Try in __________          Finish____________
                         PLEASE GIVE COMPLETE INSTRUCTIONS

 

 

 

 

 

 

 

 

Dentist's License Number__________                      ___________________________                                                                        Personal Signature of Dentist