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Get D&S Dental Dental Laboratory Work Authorization

Baraboo: 800-362-3340 Mondovi: 800-591-7964 715-926-3861 Date Infection Control Information: Full Service Certified Dental Laboratory ( ) Doctor’s Name Telephone Number Street Address City/State/Zip Impression Material Disinfected With Please Send: ❑ PVS ❑ Polyether ❑ Alginate ❑ Other ❑ Phenol ❑ Chlorine ❑ Iodophor ❑ Other ❑ ❑ ❑ ❑ ❑ Rx Forms Mailing Labels Boxes UPS Labels FedEx Ground Labels ❑ Speedee Labels Delivery: ❑ ❑ ❑ ❑ License Number.

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