Online Service Request Form
Thank you for your interest! In order to receive a price list, please fill out the following information. A price list will be sent to you by e-mail. For further information, please contact us at (212) 888-7997.

Please fill out the form below and then click send.

All fields are required.
Contact Email:
Doctor's Name:
Doctor's Address:
Zip Code:

Patient's Name:
Sex: Male Female Age:
Body Shade:
Insical Value Shade:
Metal Try-in: Bisque Bake: Glaze Finish:


Cosmetic Restoration Type:
Margin Design:
Zero Metal Collar
Connection Type:
Pontic: (You may check more than one option.)
Full Ridge Lap
Dull Texture
Alloy Type:
High Noble White 54% AU
Doctor's License Number:

By checking this box, I authorize Interdental to perform the duties that have been described above in this prescription. I understand that payment is due upon receipt of statement. Any late payment is subject to 1.5% interest per month. No work will be started unless signature and license number are provided.