Get Dental Lab Order Form

Regardless of the form the dentist chooses to use the information requested below must be included as part of the patient s treatment records and maintained as required by 18VAC60-20-15 of the Regulations Governing Dental Practice. PATIENT NAME INITIALS or ID Laboratory Name Physical Address Contact Person E-mail Address optional RETURN BY TYPE OF RESTORATION MATERIALS INSTRUCTIONS FOR WORK TO BE DONE include diagrams if needed needed ORDER to a domestic lab approved to an overseas/international lab approved to either a domestic or overseas lab approved contact me before subcontracting Dentist s Signature Dentist s Name Printed Dentist s Address Dentist s Email Address optional RESTORATION Provide the sanitized restoration in a sealed container. Guidance document 60-18 Approved December 7 2012 VIRGINIA BOARD OF DENTISTRY APPROVED TEMPLATE FOR DENTAL LABORATORY WORK ORDER FORM This form is provided by the Board to guide dentists on meeting the legal requirements for work order forms in 54. 12719 of the Code of Virginia* Dentists have the option of using this form or another form to meet the requirements of the law. Regardless of the form the dentist chooses to use the information requested below must be included as part of the patient s treatment records and maintained as required by 18VAC60-20-15 of the Regulations Governing Dental Practice. PATIENT NAME INITIALS or ID Laboratory Name Physical Address Contact Person E-mail Address optional RETURN BY TYPE OF RESTORATION MATERIALS INSTRUCTIONS FOR WORK TO BE DONE include diagrams if needed needed ORDER to a domestic lab approved to an overseas/international lab approved to either a domestic or overseas lab approved contact me before subcontracting Dentist s Signature Dentist s Name Printed Dentist s Address Dentist s Email Address optional RESTORATION Provide the sanitized restoration in a sealed container. Provide the name and physical address of the location where the restoration was fabricated* Provide a copy of the information the lab received from a manufacturer on the composition of the casting and ceramic materials used in fabrication such as an Identalloy sticker Date Dental License Telephone. Guidance document 60-18 Approved December 7 2012 VIRGINIA BOARD OF DENTISTRY APPROVED TEMPLATE FOR DENTAL LABORATORY WORK ORDER FORM This form is provided by the Board to guide dentists on meeting the legal requirements for work order forms in 54. 12719 of the Code of Virginia* Dentists have the option of using this form or another form to meet the requirements of the law. 12719 of the Code of Virginia* Dentists have the option of using this form or another form to meet the requirements of the law. Regardless of the form the dentist chooses to use the information requested below must be included as part of the patient s treatment records and maintained as required by 18VAC60-20-15 of the Regulations Governing Dental Practice. PATIENT NAME INITIALS or ID Laboratory Name Physical Address Contact Person E-mail Address optional RETURN BY TYPE OF RESTORATION MATERIALS INSTRUCTIONS FOR WORK TO BE DONE include diagrams if needed needed ORDER to a domestic lab approved to an overseas/international lab approved to either a domestic or overseas lab approved contact me before subcontracting Dentist s Signature Dentist s Name Printed Dentist s Address Dentist s Email Address optional RESTORATION Provide the sanitized restoration in a sealed container. Provide the name and physical address of the location where the restoration was fabricated* Provide a copy of the information the lab received from a manufacturer on the composition of the casting and ceramic materials used in fabrication such as an Identalloy sticker Date Dental License Telephone.