Prescription forms.
Fairmont uses two prescription slips: a full duplicate form for anything detailed, and a short pad for straightforward crown and bridge work. Both are below.
Download
Full prescription form (PDF) Crown & bridge slip (PDF)
The full form is a duplicate — white laboratory copy, yellow doctor's copy — so the practice retains a record of what was prescribed. If your practice would prefer printed pads, call the laboratory and we will arrange them. The form has a tick box for requesting more Rx sheets and plastic bags with your next delivery.
The full form, section by section
Patient information and return date sit at the top, with the return day selectable Monday to Friday. Special Instructions has its own field, alongside a tick box asking us to phone you about the case — use it whenever a case involves a judgement you want to be part of.
The design chart uses FDI notation, maxillary and mandibular, so mark the units there rather than describing them in words. Ambiguity about which tooth is being restored is entirely avoidable and does occur.
Doctor's signature is at the top right. An unsigned form is not a problem, but a form with no reachable practice number is.
Fixed prosthetics
Shade with a tooth diagram and a number field. Type of Crown offers Full Metal, 3/4 Crown Onlay, PFM, IPS Empress, IPS e.max, Tescera, Veneer, Zirconia and Cristobal+.
Alloy is split into two sections because a metal-ceramic restoration asks something different of its alloy than a full cast one. Full Metal Alloy offers yellow high gold, yellow low gold and white non-precious; Ceramic Alloy adds white high gold and white low gold.
Then the design instructions: occlusion as porcelain or combination; labial margin as metal, combination or porcelain butt; occlusal relief as positive or foil relief with a number of foils; interproximal contact as normal, broad or point with tightness normal or tight; and pontic design as modified, ridgelap, cone or hygienic.
Removable prosthetics
Type of Denture offers Cast Partial, Acrylic Partial, Complete Denture, Over Denture, Immediate Denture and Valplast.
Procedure covers the stages: Night Guard with hard or thermal, Custom Tray, Bite Block, Frame Try-in, Set-up Try-in, Finish, Reline, Rebase and Repair. Removable work is prescribed one stage at a time, and each stage verifies something the next depends on.
Teeth has fields for Shade and Mould. Mould governs the size and form of the anterior teeth, and it is what makes a denture read as belonging to the patient rather than as a generic set.
Implant cases
The current form has no implant section, so implant detail goes under Special Instructions. It needs the manufacturer and product line, the platform diameter, the connection type, whether screw or cement retention is intended, and whether a stock or custom abutment is expected.
A photograph of the component packaging from the placement appointment settles most of it in one image and is quicker than writing it out.
The implant case checklist covers the whole set.
Submitting completed forms
Send the prescription inside the package with the case, not only attached externally, so a case separated from its paperwork can still be identified.
For digital cases, the prescription information still has to travel with the file. Completed forms can also be sent through the contact page, which accepts up to four uploads.
Special instructions, staged deliveries, shade notes and attachment systems all belong on the form — the technicians read every line.
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Send a case
Digital scans and conventional impressions are both accepted. Cases move by UPS and Purolator, and Fairmont works with practices throughout British Columbia and across Canada.