Skip to content
YDL Dental Portal
  • Return to Main Website

Dr. Preference Form

Name*
Address*

Crown & Bridge Department


Preferred Type of Metal:*
Type of Interproximal Contact:*
Type of Occlusal Contact:*
Contacts Done on Solid:*
Pontic Design:*
Pontic Design Reference:
Tissue Relief for Pontic:*
Occlusal Anatomy:*

If Occlusal Space is Needed:

Permission to Relieve Opposing?*
If No, okay to use metal occlusion?*
Permission to relieve prep?*
If Yes, would you like a reduction coping?*
Extra Die Spacer*
Occlusal Stain*

Implant Department


Implant Preference:*
Preferred Abutment:*
Soft Tissue:*
Cement:*

Removable Department


Dentures:*
Partials:*
Reline:*
Identification:*

Additional Information


Would you prefer us to call or email about questions concerning a case?*
Preferred Method of Payment:*

Please note: YDL requires a valid credit card on file and a completed ACH form for all client’s prior to starting any restorations. Accounts with a balance over 30 days will be considered delinquent and YDL will charge the credit card on file for the outstanding balance due.

By typing in your legal name, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
MM slash DD slash YYYY
YDL Concert Logo
(214) 691-5512
3001 Keller Springs Road
Carrollton, TX 75006

Our History
Our Founder Featured Case

New Doctor
Shipping Label
Digital Impression

Contact Us
Resources
Certifications

Fixed
Removable
Implant

Follow Us:

© 2022 YDL
Designed by AMG Creative, inc.