Australian Dental Labs — Lab Request Form

9/72 Logistics Street, Keilor Park VIC 3042
P: (03) 9470 4500 | [email protected]
australiandentallabs.com.au

Date

Dentist

Patient Name

Clinic / Practice

Return Date

Patient Appointment

Prosthetics

Framework

UL

Full Acrylic

Partial Acrylic

Chrome Casting

Valplast

Flexible Resin

Stage

UL

Special Tray

Registration Rims

Try In Framework

Try In Teeth

Retry Teeth

Finish Denture

Repairs & Relines

UL

Basic Repair

Repair Addition

Tooth Addition

Partial Reline

Full Reline

Soft Reline

Miscellaneous

UL

Bleaching Tray

Mouth Guard

Radiographic Stent

Implant Tooth Stent

Surgical Stent/Guide

Other

Teeth: Premium | Standard

Shade:

Orthodontics

Retainer

UL

Hawley

Doner

Wrap Around/Begg

Spring Hawley

Essix/Suckdown

Removable Appliance

UL

Twin Block

Bionator

Activator

Expansion Plate

Other

Fixed

UL

Lingual Wire (3-3)

RME (Banded)

Quad Helix

Lingual Arch (6-6)

Space Maintainer

Splints & Sleep Apnoea

UL

Digital Splint

Soft

Sleep Apnoea

Tooth Chart — Draw on the diagram to mark affected teeth or add annotation

Colour

Size

Additional Instructions

Print this form and include it with your case — or save as PDF and send to [email protected]

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