Prescription
Heward Dental Lab Inc.
789 Dusty Rock Circle
Sandy, Utah 84094
Office (801) 567-1997 Steve's Cell (801) 699-9382
Patient's
Name_______________________ Phone#_________________
E-mail
_______________________________Age ______ Sex_________
Dr.____________________________ Phone#_____________________
Address_________________________ Date ______________________
_______________________________ E-mail _____________________
_______________________________ Tooth# _________ Shade______
Which side of the tooth would you like the artwork on.....
Labial (lip/cheek side)
Lingual (toward tongue)
Size of Artwork.....
Large / As large as possible
Medium / Normal size to fit on tooth
Small / As small as possible (difficult to see)
Picture or
Detailed description of what you want on the tooth.
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