Full Arch All-On-X Specialist
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All-On-X RX Form
Home
Book Services
Contact Us
About Us
813-803-5662
All-On-X RX Form
RX Form
Printable Version
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Doctor Information
Doctor's Name:
*
Practice Name
Email
*
Phone:
*
Address:
Patient Information
Patient Name
Age
Gender
Male
Female
Date
Due Date
Patient Appointment
Removable
Guards
Nightguard- Hard/Soft/Hard-Soft
Printed Models
Full Arch Implants
Full Arch
Printed PMMA Stage 1
Printed PMMA Stage 2
Milled Zirconia Stage 3 Final
Full Arch Surgical Planning
Treatment Plan
Surgical Guide
Manufacturer:
Size
Type
Checkboxes
Provide Drill
Provide Attachment/ Abutment
Case Evalution/ Scan Eval
In-Office Conversion w/tech
Items Sent
Item Sent Choice
Bite
Photos
Impression
Study Model
Implants Parts
Opposing Model
Raw. STL File
DICOM File
3D Facial Scan
Request Supplies/ Information
Checkboxes
Send Rx Forms
Send Shipping Labels
Contact Doctor
Send Lab Information
Shade
Shades
Custom Shade
Photos sent to photos@ameri-dent.com
Choose Tooth Number
1
2
3
4
5
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7
8
9
10
11
12
13
14
15
16
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18
19
20
21
22
23
24
25
26
27
28
29
30
31
Choose
Upper Arch
Lower Arch
License Number
Terms and Conditions
*
I agree to the Terms and Conditions
*
This document evidences a contract for the sale and delivery of the manufactured goods mentioned and subject to the following terms and conditions:
1. Customer agrees to pay in full the stated price of the product(s), plus any late fees.
2. Payment is due in full upon monthly statement. A late payment fee of 1.5% will be charged on any unpaid balances over 15 days from monthly statement.
3. Ameri-Dent Dental Laboratory may require a deposit or ship goods C.O.D.
4. Each order of work authorization filed, or appliance made, constitutes a complete and separate transaction to be billed and collected as such. Acceptance of new orders by Ameri-Dent Dental Laboratory shall not represent any accord and satisfaction and shall not relieve customer of any indebtedness to Ameri-Dent Dental Laboratory.
5. Any use, sale, transfer, modifications of the appliance or failure to reasonably notify and return the appliance within 14 days to Ameri-Dent Dental Laboratory, shall institute acceptance.
6. Any defects in returned goods must be particularized and Ameri-Dent Dental Laboratory retains the right to effect cure of the defect.
7. Dentists must examine all products and determine their fitness for any intended usage. There are NO express warranties and no implied warranty for a particular purpose given by Ameri-Dent Dental Laboratory.
8. Statements not paid within 60 days will be subject to C.O.D. until the account is fully current. Balances over 90 days will be turned over to our accounting department with details about moving forward with cases coming in or out.
9. This transaction shall be governed by the laws of Florida. Acceptance of goods constitutes acceptance of all terms and conditions herein. This writing evidences the complete and final expression of the agreement.
Dr. Signature
Clear Signature
Submit
Working Hours
Mon - Sat : 8AM-5PM
Sun : Closed
Copyright © 2026 Ameri-Dent Dental Laboratory, All rights reserved.
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