Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone*Crown & Bridge Department Preferred Type of Metal:* Non-Precious Noble High Noble Type of Interproximal Contact:* Light Medium Heavy Broad Type of Occlusal Contact:* No Contact Light Contact Tight Contact Contacts Done on Solid:* Yes No Pontic Design:* Full Ridge Modify Ridge Lap Point Contact No Contact Pontic in Socket Show Metal on Lingual Reduce Pontic Area to Make Snug on Ridge Pontic Design Reference: Tissue Relief for Pontic:* Light Medium Heavy Occlusal Anatomy:* Primary Secondary Copy Adjacent Tooth If Occlusal Space is Needed: Permission to Relieve Opposing?* Yes No If No, okay to use metal occlusion?* Yes No Permission to relieve prep?* Yes No If Yes, would you like a reduction coping?* Yes No Extra Die Spacer* Yes No Occlusal Stain* Yes No Implant Department Implant Preference:* Cement Retained Screw Retained (When Possible) Preferred Abutment:* Titanium Zirconia with Ti-Base Soft Tissue:* Contoured No Tissue Pressure Cement:* In Lab Chair Side Removable Department Dentures:* Rugae Stippled Postdamed Partials:* Stippled Not Over Extended Reline:* Leave Borders As Is Not Over Extended Identification:* Yes No Additional Information Would you prefer us to call or email about questions concerning a case?* Call Email Preferred Email* Preferred Phone*Monthly Statement Email Address (if different from office email): Preferred Method of Payment:* ACH Check by Mail 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.Signature of Person Completing Form* 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.Date* MM slash DD slash YYYY Additional Comments