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3M ORAL CARE PREFABRICATED CROWN ORDER FORM
Name_____________________________________________________________________________
Phone_____________________________________
Address _____________________________________________________________________________________________________________________________
City ____________________________________________________________
State _______________
Zip _______________________________
Instructions:
This order form is formatted the same as the 3M Oral Care crown kit drawers to allow for easy ordering. Fill in spaces with the number of refill boxes for each size. If there are two sizes in
a space, circle the appropriate number. Refill boxes contain 5 crowns
.
Fax: 888-681-5088
or call your DHPI Account Manager at
800-626-2163
Primary Anterior
Centrals (Black)
Laterals (Red)
Cuspids (U=Green L=Blue)
UL1
907001UL2
907002UL3
907003UL1
907021UL2
907022UL3
907023U1
907041U2
907042U3
907043UL4
907004UL5
907005UL6
907006UL4
907024UL5
907025UL6
907026U4
907044U5
907045U6
907046UR1
907011UR2
907012UR3
907013UR1
907031UR2
907032UR3
907033L1
907051L2
907052L3
907053UR4
907014UR5
907015UR6
907016UR4
907034UR5
907035UR6
907036L4
907054L5
907055L6
907056Permanent Molar
First Molar
Second Molar
UR-1
900321UR-7
900327UR-7
900327UR-7
900327UR-7
900327UR-7
900327UR-7
900327LR+1
900441LR+2
900442LR+3
900443UL-1
900311UL-7
900317UL-7
900317UL-7
900317UL-7
900317UL-7
900317UL-7
900317LR+4
900444LR+5
900445LR+6
900446LR-1
900341LR-7
900347LR-2
900342LR-3
900343LR-4
900344LR-5
900345LR-6
900346LL+1
900431LL+2
900432LL+3
900433LL-1
900331LL-7
900337LL-2
900332LL-3
900333LL-4
900334LL-5
900335LL-6
900336LL+4
900434LL+5
900435LL+6
900436Permanent Bicuspid
Maxillary
First Mandibular
Second Mandibular
UR1
900521UR2
900522UR3
900523LR•1
900541LR•2
900542LR•3
900543LR1
900641LR2
900642LR3
900643UR4
900524UR5
900525UR0
900520UR6
900526UR00900519
LR•4
900544LR•5
900545LR•6
900546LR•0
900540LR4
900644LR5
900645LR6
900646LR0
900640UL1
900511UL2
900512UL3
900513LL•1
900531LL•2
900532LL•3
900533LL1
900631LL2
900632LL3
900633UL4
900514UL5
900515UL0
900510UL6
900516UL00
900509LL•4
900534LL•5
900535LL•6
900536LL•0
900530LL4
900634LL5
900635LL6
900636LL0
900630Primary Molar
First Primary
Second Primary
UR1
900121UR7
900127UR2
900122UR3
900123UR4
900124UR5
900125UR6
900126UR1
900221UR7
900227UR2
900222UR3
900223UR4
900224
UR5
900225UR6
900226UL1
900111UL7
900117UL2
900112UL3
900113UL4
900114UL5
900115UL6
900116UL1
900211UL7
900217UL2
900212UL3
900213UL4
900214UL5
900215UL6
900216LR1
900141LR7
900147LR2
900142LR3
900143LR4
900144LR5
900145LR6
900146LR1
900241LR7
900247LR2
900242LR3
900243LR4
900244LR5
900245LR6
900246LL1
900131LL7
900137LL2
900132LL3
900133LL4
900134LL5
900135LL6
900136LL1
900231LL7
900237LL2
900232LL3
900233LL4
900234LL5
900235LL6
900236Primary Molar
Left
Upper
Right
D-UL-7 D-UL-6 D-UL-5 D-UL-4 D-UL-3 D-UL-2 D-UR-2 D-UR-3 D-UR-4 D-UR-5 D-UR-6 D-UR-7
E-UL-7 E-UL-6 E-UL-5 E-UL-4 E-UL-3 E-UL-2 E-UR-2 E-UR-3 E-UR-4 E-UR-5 E-UR-6 E-UR-7
D-LL-7 D-LL-6 D-LL-5 D-LL-4 D-LL-3 D-LL-2 D-LR-2 D-LR-3 D-LR-4 D-LR-5 D-LR-6 D-LR-7
E-LL-7 E-LL-6 E-LL-5 E-LL-4 E-LL-3 E-LL-2 E-LR-2 E-LR-3 E-LR-4 E-LR-5 E-LR-6 E-LR-7
Lower
Anterior — Upper Centrals
Patient’s Right
Upper Centrals
Patient’s Left
UR 1
914011UR 2
914012UR 2
914012UL 1
914001UL 2
914002UL 2
914002UR 3
914013UR 3
914013UR 4
914014UL 3
914003UL 3
914003UL 4
914004Anterior — Upper Laterals
Patient’s Right
Upper Laterals
Patient’s Left
UR 1
914031UR 2
914032UR 2
914032UL 1
914021UL 2
914022UL 2
914022UR 3
914033UR 3
914033UR 4
914034UL 3
914023UL 3
914023UL 4
914024Permanent Molar
Left
Upper
Right
6-UL-4
6-UL-3
6-UL-2
6-UR-2
6-UR-3
6-UR-4
6-UL-7
6-UL-6
6-UL-5
6-UR-5
6-UR-6
6-UR-7
6-LL-4
6-LL-3
6-LL-2
6-LR-2
6-LR-3
6-LR-4
6-LL-7
6-LL-6
6-LL-5
6-LR-5
6-LR-6
6-LR-7
Lower
Molar
Left
Upper
Right
U69 U67 U65 U63 U61 U60 U62 U64 U66 U68 U79 U77 U75 U73 U71 U70 U72 U74 U76 U78 L69 L67 L65 L63 L61 L60 L62 L64 L66 L68 L79 L77 L75 L73 L71 L70 L72 L74 L76 L78Lower
Bicuspid
Left
Upper
Right
U49 U47 U45 U43 U41 U40 U42 U44 U46 U48 U59 U57 U55 U53 U51 U50 U52 U54 U56 U58 L49 L47 L45 L43 L41 L40 L42 L44 L46 L48 L59 L57 L55 L53 L51 L50 L52 L54 L56 L58Lower
Prefabricated Crowns
3M Oral Care Stainless Steel Crowns 5/box
Unitek
™
Stainless Steel Crowns 5/box
Iso-Form
™
Crowns 5/box
3M Oral Care Pediatric Strip Crown Forms 5/box
154
CROWNS