Maverick Clinical Preference Form

Please note: Written instructions on the script will always supersede preferences saved to your account. Preferences may be changed anytime.

    OFFICE INFORMATION

    Practice Name:

    Street Address:

    City:

    State:

    Zip Code:

    Office Phone:

    Office Email:

    Doctor Name:

    Doctor Cell #:

    Doctor Email:

    How would you prefer to be contacted? Mark all that apply.

    Preferred Email:

    BILLING PREFERENCES

    Address (If different than shipping address)
    Billing Street Address:

    Billing City:

    Billing State:

    Billing Zip Code:

    Billing contact name:

    Billing contact email:


    ADDITIONAL TEAM MEMBERS

    Please list any additional team member names, phone #, and emails:

    CROWN & BRIDGE PREFERENCES

    Occlusal Clearance:

    If you selected “Out of occlusion __ mm,” please specify below:

    Interproximal Contacts:

    Unclear Margins:

    Insufficient Clearance:

    If you selected “Reduce opposing by __ mm max,” please specify:

    Bridge Pontic Design:

    IMPLANT PREFERENCES

    Abutment Manufacturer:

    Abutment Type:

    Gingival Emergence:

    In cases of lingual implant position:

    When screw retained is requested, but not possible after lab evaluation:

    REMOVABLE PREFERENCES

    Occlusal Splint Material:

    Occlusal Splint Design:

    Metal Partial Clasps:

    Teeth Selection:

    If you selected “Special Order,” please specify: