ToothArtist.com
Your Subtitle text

Prescription

ToothArtist.com

Heward Dental Lab Inc.
789 Dusty Rock Circle
Sandy, Utah 84094

Office (801) 567-1997

  Cell (801) 699-9382

contact@toothartist.com

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.
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

......Other instructional details: