Dorsey Dental Lab, Inc. Rx Sign up to Submit Cases Online 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 Doctor(Required) License Address(Required) City State / Province / Region ZIP / Postal Code Phone(Required)Patient Name(Required) Will opposing teeth be restored? Yes No Date Wanted (Weekdays Only by 5 PM) MM slash DD slash YYYY Tooth # Shade Type of Case Full Contour Zirconia Layered Zirconia Full Contour e.Max Layered e.Max PFM Other Type of Metal (Full Cast) Semi-Precious Gold Color Semi-Precious Silver Color Yellow Gold White Gold Non-Precious Type of Metal (PFM) Semi-Precious Non-Precious Yellow Gold White Gold Work Authorization Order Construct and deliver to the undersigned only the herein dental restoration.Date MM slash DD slash YYYY Instructions
