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New Client Form

“Thank you for choosing ALAI as your Laboratory Services company. Please fill the New Member form below and submit it online. If you prefer, you can also download the application, fill it out and email it back to our team at: clientapp@alaienterprises.com or fax to 561-401-9669.”

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Client Profile Information
Practice Doctors:

Name of Doctor:

Doctor ID #:

Name of Doctor:

Doctor ID #:

Name of Doctor:

Doctor ID #:

Practice Information

Practice Name:

Practice Mailing Address:

Street:

Suite#:

City:

State:

Zip Code:

Practice Phone Number:

Area Code:

Number:

Practice Fax Number:

Area Code:

Number:

Contact Person:

Name:

Email:

Phone:

Billing Information:
Billing Mailing Address:

Street:

Suite#:

City:

State:

Zip Code:

Billing Phone Number:

Area Code:

Number:

Billing Fax Number:

Area Code:

Number:

Billing Contact Person:

Name:

E-Mail:

Phone:

Preferred Billing Method:

Email:

US Postal Service:

Client Product Preferences:
Product Preference:
Nightguards:

 0.5mm Occl Cuspal Indet 2 Ball Clasps t Anterior Contact, Posterior Disclusion Anterior Disclusion Anterior Guidance Do Not Cover Palate Flat Occlusal Plane Lower Lower Hard Occlusal Splint Opposing Not Needed Upper Acrylic Splint

Model Department - Dept. Preference / Crown & Bridge
Modelwork:

 2 Solid Models Do Not Write On Models Double Pin Dies No Epoxy Models Pour Impressions Completely Quad Impressions For Master Die

Die Spacer:

 1 Coat 2 Coats 3 Coats 4 Coats 5 Coats Minimal No Die Spacer

Die Trim:

 Always Die Trim Bevel Feather Knife Edge Never Die Trim No Bevels Shoulder

Product Group Preference:
Alloy:

 NP - Non Precious / Base Noble - Semi Precious High Noble High Noble - 75% Gold

Dept. Preference / Crown & Bridge:
Margin Prep:

 0.5mm Sub-gingival 0.5mm Supra-gingival 0.5mm-0.75mm Sub-gingival 1.5mm-2mm Sub-gingival 1mm Sub-Gingival 1mm Supra-gingival Facial 2mm Supra-gingival Lingual Do Not Prep Beyond Gumline Extend Margins to Gingival

Product Group Preference:
Metal Design:

 0.25mm Hairline Margins 0.5mm Buccal Hairline Margins 0.5mm Hairline Margins 0.5mm Lingual Collar 180° Metal Collar 1mm Lingual Collar 2mm Lingual Collar 360° Metal Collar 360° Metal Hairline Margins All Porcelain Butt Shoulder 360 Facial Butt Shoulder 180 no collar Facial Butt Shoulder 180 w/collar High Lingual Keep Thin High Lingual Keep Thin Lingual Collars Always Lingual Removal Buttons Metal Linguals Collars Metal Occlusal no Buccal Cusp Metal Occlusal w/ Buccal Cusp No Facial Metal No Lingual Collars No Lingual Removal Buttons No Metal Islands No Metal Linguals No Metal Occlusals No Strut Designs Show No Metal Strut Design Always Thin Hairline Lingual Collars Thin Lingual Collars

Dept. Preference / Crown & Bridge:
Pontic Design:

 2mm Socket Pontics 3mm+ Ovate Pontics Adjust Ridge Bullet Do Not Adjust Ridge Modified Ridge Lap No Ovate Pontics No Ridge Laps Ridgelap

Porcelain Department - Dept. Preference / Crown & Bridge:
Anatomy:

 10° Cusps Anatomy on Linguals Flat Occlusal Follow Adjacent Teeth Functional No Cervical Grooves No Facial Anatomy Primary Only Rounded Cusp Tips Thin Incisal Edges Worn Anatomy

Contacts:

 Broad Broad Light Broad Tight Convex Heavy Light Normal Primary Only Slightly Open Tight Wide

Clearance:

 Mark / Reduce Opposing Metal Lingual Broad Tight Metal Occlusal Reduction Coping Reduction Coping 0.5mm Spot Spot - Natural Dentition Spot 0.5mm Spot 0.5mm - Natural Dentition Spot 1mm

Occlusion:

 1 Foild Opposing 1 tape out 2 Foil Opposing 2 tape out 3 tape out Die Spacer on Opposing In Occlusion Light Occlusion Spot 0.5mm Out of Occlusion Tight

Occlusal Staining:

 Dark Light on Molars and Bicuspids Medium None

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Why ALAI Labs?

We have 100 years of combined experience, technical skills and state-of-the-art technology, we take pride in crafting dental restorations that satisfy your specifications.

Call us Today Toll Free: (866) 365-6944

Call Alai Labs Today Toll Free: 866-355-6944
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