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1-2719 of the Code of Virginia. Owners have the option of using this form or another form to subcontract all or part of a dentist s work order to another dental laboratory subcontractor. Guidance document 60-19 Approved December 7 2012 VIRGINIA BOARD OF DENTISTRY APPROVED TEMPLATE DENTAL LABORATORY SUBCONTRACTOR WORK ORDER FORM This form is provided by the Board to guide owners of dental laboratories owners on meeting the legal requirements for work order forms in 54. Regardless of the form the owner chooses to use the information requested below must be included in the work order sent to the subcontractor. The owner is required to retain a copy of the order to attach the copy to the order received from the dentist and to maintain both orders for three years. PATIENT NAME INITIALS or ID Subcontractor Name Physical Address Contact Person E-mail Address optional Return by Instructions Signature Name Printed Address Date Telephone. Regardless of the form the owner chooses to use the information requested below must be included in the work order sent to the subcontractor. The owner is required to retain a copy of the order to attach the copy to the order received from the dentist and to maintain both orders for three years. The owner is required to retain a copy of the order to attach the copy to the order received from the dentist and to maintain both orders for three years. PATIENT NAME INITIALS or ID Subcontractor Name Physical Address Contact Person E-mail Address optional Return by Instructions Signature Name Printed Address Date Telephone. Regardless of the form the owner chooses to use the information requested below must be included in the work order sent to the subcontractor. The owner is required to retain a copy of the order to attach the copy to the order received from the dentist and to maintain both orders for three years. PATIENT NAME INITIALS or ID Subcontractor Name Physical Address Contact Person E-mail Address optional Return by Instructions Signature Name Printed Address Date Telephone.

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