CLIENT PREFERENCES FORM
Filling out this form allows us to create an account for your practice, and provide best in class dental laboratory work according to your specified preferences. We recommend one preferences form per provider within the practice.
Doctor Name
*
First Name
Last Name
Doctor License #
*
State
*
State doctor is licensed within
Office Phone
*
Doctor Cell Phone
Doctor Email
*
example@example.com
Practice Name
*
Practice Contact Person
*
Contacts Phone
*
Contacts Email
*
example@example.com
Address (where statements / invoices are sent)
*
Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip
Preferred Method of Communication (how should we contact you with any ?'s on your cases)
*
Text
Call
E-Mail
Affiliations: (ex. ADA AACD)
How did you hear about Leixir?
Type of Practice (Select ALL that apply)
*
General Dentistry
Cosmetic
Family Dentistry
Implant
Maxillofacial Surgery
Orthodontics
Periodontics
Prosthodontics
Reconstructive
Restorative
Private Practice
DSO (more than 3 locations / same ownership)
Reason for Selecting Leixir Dental Group
There are 3 sections below, Fixed, Removable, and Implant Preferences. Please fill in as much info as you can.
The more info you provide, the better our work will be for you and less of a chance for a remake.
FIXED PREFERENCES
Preferred Posterior Crown (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
*
Solid Zirconia (or FCZ) (RECOMMENDED)
PFZ (Porcelain fused to zirconia)
Lithium Dislocate (EMAX)
CAC (Picasso)
PFM (Porcelain infused to metal)
Nonprecious (silver)
Semi-Precious (silver)
High Noble Yellow Gold
High Noble White Gold
Full Cast Crown (FCC)
FCC Nonprecious (silver)
FCC Semi-Precious (silver)
FCC High Noble Yellow Gold
FCC High Noble White Gold
Occlusion (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Out of occlusion (default)
Point Occlusion
Way out of occlusion
Interproximal Contacts. (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Normal / Passive (default)
Broad, Tight contacts
Open
Anatomy (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Match Adjacent Teeth (default)
Detailed
Minimal
Occlusal Staining
Light (default)
None
Glaze Type (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Low Luster
Medium Luster
High Luster
If Limited Occlusal Clearance
Trim opposing (default)
Trim die & Fabricate reduction coping (voids warranty)
Contact me via cell, text, or e-mail
Tooth Shade Guide Preferred
Vita (default)
Ivoclar
Other
Pontic Design. (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Modified Ridge
No Contact
Full Ridge
Point Contact
Unclear Margins
Call Office (default)
Email office with scans (digital)
Return to doctor (Analog)
Make as is - Remake fees may apply
Articulator Type (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Plastic (default)
Panadent
Denar
Kavo
Metal Hinge
Printed
Other
REMOVABLE PREFERENCES
Fill out this section if you plan to submit (now or in future) Removable Cases
Denture / Partial Base (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Acrylic Base (default)
Cast metal base
Flex base
Printed
Will indicate on Rx
Other
Finishes (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
100% Muscle Trim
Rug
Stippling
Smooth
Characterized
Preferred Nightguard Type (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Hard
Soft
Hard / Soft
Occlusal Options (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Lingualized occlusion
Centric occlusion
MI occlusion
Occlusal Guards (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Canine Guidance
Flat Plane Group Function
Nightguard Finish (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Full arch coverage (default)
Anterior Coverage
Open Anterior
Anterior Ramp
Denture Teeth (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Premium (standard)
Economy
Cast Frame Options (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Premium (i.e. Vitallium) - default
Economy
IMPLANT PREFERENCES
Fill out this section if you plan to (now or in future) send us implant cases
Crown Type (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Zirconia (default)
Layered Zirconia
CAC (Picasso)
Lithium Disilicate
PFM
Abutment & Restoration Design (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Custom Milled
TI Base (default)
Zirconia
Margin Depth B-F (DEFAULT is 1.5mm) - type your own if you want other than default)
Margin Depth M-D (DEFAULT is .5mm) - type your own if you want other than default
Margin Depth L (DEFAULT Is 0.5mm - type your own if you want other than default)
Place, Restore, or Place and Restore. Who provides parts.
Lab (Default)
Doctor
Custom Jig Required (custom abutment only)
YES
NO
Parts Preferences (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Leixir (Default)
OEM (Note OEM on Rx)
Restoration Design (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Screw-retained (one piece, lab cemented)
Cement - no access hole w/ seating jig)
Screwmentable (two piece with crown access hole, abutment, seating jig)
Anodized Abutment (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Yes (default)
No
Abutment Margin Depth (TYPE PREFERRED DEFAULT - when you submit a case you can specify different on Rx)
Please type preferred depth
If screw access hole exits facial due to angulation (CHOOSE ONE DEFAULT - when you submit a case you can specify different on Rx)
Switch to ASC (fees may apply)
Switch to Cement
Contact Me (text, cell, email)
What ASC Drivers to you use?
Design Approval Required
No (default)
Yes (contact office)
Thank you for filling out this form, by clicking submit below we will e-mail a copy of the completed form to you (doctor e-mail you specified at beginning of this form), and attach it to your Leixir profile so all of our lab technicians can access when you send cases.
Thanks for using Leixir Dental Laboratory Group
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