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Free Dental Lab Rx Form (Crown, Bridge, Implant)Fill Online, Save as PDF

No sign-up, no email. Nothing you type leaves this browser.

Nothing on this page is sent or saved anywhere.

When you close or reload this page, everything you typed is gone. Save the PDF first.

  1. Fill in the fields and tap the teeth on the chart.
  2. Press Print / Save as PDF. To get a file, pick “Save as PDF” as the printer.
  3. Send the PDF with your scan or impression to your lab.
Blank PDF Prints on one page, A4 or US Letter. Prefer paper? The blank PDF prints the same form empty.
Dental Lab Prescription (Rx)Crown · Bridge · Implant
Lab and practice
Patient and dates
Case
Case type Other:
Patient’s rightPatient’s left
Upper (maxillary) 1–16
Lower (mandibular) 17–32
Material and design
Material Other:
Occlusal contact Other:
Proximal contact Other:
Pontic design (bridge) Other:
Implant (implant cases only)
Abutment
Retention
Scan source
Scanner (optional):
Special instructions
Dentist signature
Date

Sign by hand after printing.

Prescription requirements vary by state. Check your state dental board rules for required elements.

Outsourcing CAD design? See how to send a 3Shape case to a design service →

Form template by SubDesignCenter. Free to use.

Questions

Is my patient information stored anywhere?

No. The form runs only in your browser. Nothing you type is sent to a server or saved on this site, and it is gone when you close or reload the page, so save the PDF first. You can use a patient ID or case reference instead of a name.

Can I use this form with any dental lab?

Yes. It is a general crown, bridge and implant prescription. Save the PDF and send it with your scan or impression to the lab you use. A lab can add its name and hand the form to its dentists.

Does it work with any scanner?

Yes. Choose intraoral scan, desktop model scan or physical impression, and add the scanner name if you like. The form only records the case details; send your scan files the way your lab asks.