§ 73-9-55. Authorization for dental laboratory work

MS Code § 73-9-55 (2019) (N/A)
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(1) Date signed.

(2) The name and address of the commercial dental laboratory or private dental laboratory technician.

(3) The name or identification number of the patient for whom the act or service is ordered.

(4) The licensed dentist’s name, address, and license number.

(5) The signature of the licensed dentist.

(6) The description of the kind and type of appliance, process, fabrication, service, or material ordered.