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TTC Reference number

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* 1. TTC Reference number

Dentist name

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* 2. Dentist name

Date Fitted

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* 3. Date Fitted

On what date was this restoration fitted?
Cement Used

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* 4. Cement Used

What was the quality of the crown like?

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* 7. What was the quality of the crown like?

  Excellent Good Average Poor
Marginal Fit
Anatomic Form
Overall Aesthetics
Was there any adjustment required on this restoration by yourself?

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* 8. Was there any adjustment required on this restoration by yourself?

  None Minor Significant Cooling Polish
Occlusal
Marginal
Contact
Fit Surface

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