Please let us know how we did. Your feedback is valuable. Thanks!

Removable Prosthetics: (select one)

• Denture
• Partial
• Implant
• Ortho
• Splint
• Flexible Partial

Fixed C & B: (select one)

• PFM
• Bridge
• FCG
• E.MAX
• Solid Zirconia
• PFZ

Doctor: *

Were instructions followed?

• YES
• NO

Patient: *

Did we pick up & deliver the case on time?

• YES
• NO

Case Number

Fit:

• Correct
• Loose
• Tight

Contour:

• Correct
• Under
• Over

Margin:

• Correct
• Short
• Long

Contacts:

• Correct
• Loose
• Tight

Occlusion:

• Correct
• Short
• High

Shade:

• Correct
• Light
• Dark

Overall Appearance:

• Perfect
• Good
• Needs Improvment

Approximate time to seat (in minutes):

Additional Comments:

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