______________________________________________________________________________
(Date) ______, 2___ |
TO: (Name of dental technician or laboratory with address) |
RE: (Name or number of patient) |
(Description of the work to be done, including diagrams if necessary, together with specifications of the type of materials to be used.) |
(Name of ordering dentist) |
(Address) ______ |
(Current license number) ___ |
______________________________________________________________________________
ORS 679.176