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CNDL GLOBALESTD. 2015
Chishtiya Nizamia Dental Laboratory · Khilgaon, Dhaka

419/1/C Khilgaon (West Side of Jorpukur Field), Dhaka-1219, Bangladesh
Hotline: +880 1743-167963 / +880 1805-976351  |  Web: cndl-global.com

LAB PRESCRIPTION SLIP
RX NO: CNDL-__________
DATE: ____ / ____ / 2026
1. Clinical Intake & Clinician Details
Doctor's Name:Dr. ____________________________________
Dental Clinic / Hospital:__________________________________________
Doctor's Phone:+880 ________________
Required Delivery Date:____/____/2026
Patient Name:______________________
Age / Gender:____ Yrs
[ ] M[ ] F
2. Anatomical FDI Tooth Chart (Circle or Click to Select Restorations)Click numbers to highlight
RIGHT (UR - Q1)UPPER JAW (MAXILLARY)LEFT (UL - Q2)
RIGHT (LR - Q4)LOWER JAW (MANDIBULAR)LEFT (LL - Q3)
3. Prescribed Dental Product & Material Selection (15 Laboratory Lines)
A. Zirconia & All-Ceramic
B. Porcelain (PFM & Metal)
C. Dentures & Orthodontics
4. Prosthetic Engineering & Aesthetic Specifications
Shade Selection (Vita Classical / Bleach):Stump / Prep Shade: [                  ]
Other / 3D Master: [ ________________ ]
Pontic Design:
Margin Design:
Occlusal Clearance:
Special Clinical Instructions / Case Notes: