Dorsey Dental Lab, Inc. Rx Sign up to Submit Cases Online 210 N. 13th 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 EmailThis field is for validation purposes and should be left unchanged.
