Keller Tooth Chart
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1Today’s Date:
Return by 5pm on:
KELLER LABORATORIES, INC.
Please send:
Prescriptions
Boxes
Case Bags
_________________
__________________
160 Larkin Williams Industrial Court
Mailing Labels:
Fenton, MO 63026
Pre-paid Fed Ex Labels
Pre-paid Mail Labels
** If return date is not specified, will default to regular lab
636-600-4200 • 800-325-3056
working times. “ASAP” does not qualify as a date.
DOCTOR:
PATIENT:
(FIRST)
(LAST)
STREET:
Male
Female
AGE:
CITY:
STATE:
ZIP:
DENTURES & PARTIALS
(
)
FAX:
(
)
PHONE:
Choose Arch
EMAIL:
Full Denture
Upper
CROWN & BRIDGE
Partial Denture
Lower
All-Ceramic
Keller Implant Options
ClearFrame
Porcelain to Metal
Choose Step
SoftTite
BruxZir Solid
Non-Precious (white)
Complete I
Complete II
Zirconia
Metal Frame
Try-In
Noble/Semi-Precious (white)*
BruxZir
Semi-Precious
Anterior Total
Complete
All Acrylic
High Noble (white)
Zirconia
KZ
e.max
3
Captek
Tooth Choice
IPS e.max
Clasps
Includes: Titanium Abutment & choice of crown.
e.Z
Economy
(Zirconia Occlusal w/
Metal Try In
Bisque
Finish
Wire Clasp
ceramic facial)
Premium
Full Cast Yellow Gold
KZ
3
(Zirconia Substructure
Ball Clasp
Implant w/ Dr. Abutment provided
w/ Ceramic overlay)
63%
46%*
20%
Clear Clasp
Empress
Choose Acrylic Shade
Semi-Precious
BruxZir
Empress w/ cutback
* Default if no Crown is specified
Flexibles
Pink
e.max
KZ
3
PFM Design
Default design is Full Porcelain with
Lt. Ethnic
DuraFlex
Chart
No Metal Collars
Dark Ethnic
Valplast
Implant w/ Dr. Abutment in place
If alternate design is needed, please circle
Porcelain
Semi-Precious
BruxZir
Butt Margin
INSTRUCTIONS:
e.max
KZ
3
Yes, on tooth
B
C
E
Shade: _______________ Mould: _______________
# (s)
________
Screw-Retained Crowns
Lingual Collar
Lingual Collar
Full Metal
Name in Denture
Occlusion
Only
w/ Narrow Facial
Lingual
Semi-Precious
BruxZir
In occlusion
M
H
J
K
Slightly out of
occlusion*
Lingual Collar
Buccal Hooded
Lingual Collar
Lingual Cusps
Out of occlusion
Only
Porcelain Veneer
w/ Narrow Buccal Collar
Metal
* Default if not specified
Tooth #’s _______________________
Shade _____________ or
see shade map
Crown prepped for
future partial
Send photos to
Doctor Signature ______________________________________
License No. _____________________________
Terms are net 10 days from statement date.
Please include doctor and patient name in email.
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Parent category: Medical