Doctor*

Pt. Last Name or ID*

Invoice #

Metal Margins
ExcellentOver-ExtendedShortUnacceptable

Porcelain Margins
ExcellentGoodFairUnacceptable

Contour
ExcellentGoodFairUnacceptable

Contacts
PerfectMinimal AdjustmentHeavy AdjustmentMissing

Occlusion
PerfectMinimal AdjustmentHeavy AdjustmetMissing

Shade
ExcellentGoodFairUnacceptable

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Please contact me regarding this caseThis case is being returned to ADT