1.impression tray for working model
2.opposite  model
3.bite registration (if necessary)
4.This form

Date: ___ /___ /____

Dentist: ________________

Clinic:   ______________

PT's Name: _____________

M F  Age:  _______

Crowns #_____.
Bridges #_____.
Fused to Metal #_____.
Full Metal #_____.
In-Ceram #_____.
Empress2 #_____.
Composite #_____.
Porcelain Inlay, Onlay #_____.
Porcelain Veneer #_____.
Post & Core #_____.
Other _________.

Metal
Non-Precious(Non Be)
Palladium Base
Semi Precious(Au:51.2%)
Precious 88%

Margin
Metal____mm
Porcelain Margin____mm
(Only if Shoulder is prepare)

Occlusal
Porcelain #____.
Metal #____.

Groove
Stain#____.
Non-Stain#____.

Joint____________________________
________________________________
________________________________

Embrassure_____________________
________________________________
________________________________

Characterization for: Teenagers Adults Elders

Additional Comment
____________________________________
____________________________________
____________________________________
____________________________________