Skip to content
7362 University Ave NE, Suite #300, Fridley, MN 55432
info@adlmn.com
+(1) 763-571-4887
Facebook-f
Twitter
Github
Bitbucket
Home
Products & Services
Schedule Pickup
RX FORM
About Us
Home
Products & Services
Schedule Pickup
RX FORM
About Us
contact us
Have a perfect smile!
Home
|
RX FORM
RX Submission Form
Download Here
Dentistry Information
Dentistry
Doctor's Name
Phone Number
E-mail
Address
City
State
Zip
Case Information
Patient Name
Sex
Male
Female
Prep Date
Due Date
Design:
Anterior
Posterior
Pontic
Restoration:
Crown
Bridge
Veneers
Implant
Fit to Partial
Model
Remake
Metal Type:
Zirconia
Emax
Gold
PFM
PFM / Alloy Selection:
Non-Precious
Semi-Precious
High Noble White
High Noble Yellow
Shade
Select Crown(s) Number:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Notes:
License
Dr. Signature
SEND A CASE
Download Here
