Dorsey Dental Lab, Inc.

Dorsey Dental Lab, Inc. Rx

Dorsey Dental Lab, Inc.

1227 W. Walnut Street, Rogers, AR 72756    479-621-8885    866-784-1525    Fax 479-621-6811

2013 N. Green Acres Road, Ste A, Fayetteville, AR 72703 479-621-8885  866-784-1525 Fax 479-621-6811

1960 E. Bay Drive, Largo, FL 3377  727-230-186

Doctor_____________________________________  Address____________________________________                                     


Phone (     )_________________________________


Patient Name: ______________________________Will opposing teeth be restored? ___Yes   ___No

Date Wanted____________ Time_____________

Tooth #__________________________________Shade____________________________________

Type of Case______________________________

___Full Contour Zirconia    ___Layered Zirconia  ___Full Contour e.Max     ___Layered e.Max

___PFM   ___Economy  ___Other

Type of Metal

___24 kt. Gold   ___Yellow Gold   ___White Gold   ___Semi-Precious   ____Non-Precious                                

___Full Cast Yellow Gold     ___Full Cast Semi-Precious   ___Full Cast Non-Precious


Work Authorization Order

Construct and deliver to the undersigned only

the herein dental restoration.

Dentist’s Signature_________________________________License_________________________Date______________