Healthcare Dental Engineering Form

Healthcare Dental Engineering Form

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical & Dental History

Bleeding disorders: Yes No    Pregnant or planning pregnancy: Yes No

Dental Engineering Prescription

License / NPI (if applicable):

Crown Bridge Veneer Partial Denture Full Denture Implant Restoration Night Guard Orthodontic Appliance

Physical impression Digital scan Existing model

Try-in required: Yes No

Standard (normal) Expedited — Days:

Shipping & Return

Carrier preference / account number:

Authorization, Consent & Legal Terms

By signing below, Patient Name: hereby authorizes the fabrication and modification of dental appliances and restorations in accordance with the specifications set forth in this form. The patient affirms that the information provided is accurate and complete to the best of their knowledge and that the prescribing clinician has been informed of relevant medical history.

Patient authorizes release of clinical records, impressions, models, and digital scans to the dental laboratory or engineering facility for purposes of fabrication and quality control. Patient acknowledges that the laboratory may subcontract certain fabrication steps to qualified providers and that clinically necessary modifications may be made to fit and function within accepted professional standards.

Patient understands and accepts the following risk and warranty conditions: dental restorations and appliances are subject to material limitations, wear, fracture, and occlusal adjustment; color and shade matching cannot be guaranteed; warranties, if any, are limited to replacement or repair for a defined period and do not cover damage due to trauma, parafunctional habits, or failure to follow aftercare instructions. Claims for laboratory error or fabrication defects must be reported in writing within 14 days of delivery; diagnostic models, impressions, or digital files may be retained by the laboratory for quality assurance unless otherwise requested in writing.

I acknowledge that fees for laboratory work are owed to the laboratory by the ordering clinician or patient as agreed between clinician and laboratory. Cancellation or revision after work has commenced may result in additional charges. The laboratory and prescribing clinician are authorized to exchange information necessary to complete fabrication and resolve technical issues.

HIPAA Privacy Acknowledgment: I acknowledge that I have been informed of the use and disclosure of my protected health information for the fabrication of dental restorations and agree that such information may be used by the laboratory for treatment, payment, and health care operations related to the services described above.

If signing on behalf of the patient, indicate relationship below and confirm legal authority to consent.

Acknowledgments (select all that apply)

I request a copy of the prescription and fabrication instructions.

I consent to release of impressions / scans to the dental laboratory.

I understand the risks, limitations, and potential need for future adjustments or replacements.

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