Crown & Bridge Department

Preferred Type of Metal *
Type of Interproximal Contact *
Type of Occlusal Contact *
Contacts Done on Solid *
Pontic Design *

Pontic Design Reference:

Tissue Relief for Pontic *
Occlusal Anatomy *

If Occlusal Space is Needed:

Permission to Relieve Opposing? *
If No, okay to use metal occlusion? *
Permission to relieve prep? *
If Yes, would you like a reduction coping? *
Extra Die Spacer *
Occlusal Stain *

Implant Department

Implant Preference *
Preferred Abutment *
Soft Tissue *
Cement *

Removable Department

Dentures *
Partials *
Reline *
Identification *

Additional Information

Would you prefer us to call or email about questions concerning a case? *
Preferred Method of Payment *

Please note: YDL requires a valid credit card on file and a completed ACH form for all client’s prior to starting any restorations. Accounts with a balance over 30 days will be considered delinquent and YDL will charge the credit card on file for the outstanding balance due.

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