Dd Form 2322 - Dental Laboratory Work Authorization

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LABORATORY DATA
1. Name of Dental Laboratory
1. Local Case No.
2. Name of Treatment Facility, Mailing Address & DSN No.
3. ADL Case No.
2.
3.
4. Teeth, Facings or Pontics
Date
Date
4. Patient's Name (Last, First, Middle Initial)
5. Grade
6. Age
7. Date Initiated
Location
Tooth Nos.
Shade
Guide
Mold
Received
Completed
Max Ant
8. Beneficiary Type
9. Organization, Duty and Home Telephone Nos.
10. Date Forwarded
Max Post
Man Ant
11. Type of Prosthesis or Restoration
12. Shade and Mold by Guide
13. Date Delivered
Man Post
5. Articulator
6. Metals Voucher No:
14. Prosthesis Design
Metals Used
Out
In
Used
Type
DWT
GR
DWT
GR
DWT
GR
Number and Settings
MANDIBULAR
7. Laboratory Remarks, Instructions, or Consultation Report
MAXILLARY
Request(s)
(Check appropriate box(es))
15.
Framework Only
16.
Set-up
17.
Process
18.
Fully Fabricate
19.
Bisque Bake
20.
Consultation
21.
Diagnostic Casts
22.
Jaw Relation Record
23.
Radiographs
24.
Other (See remarks)
25. Clinician's Remarks/Instructions
8. Typed Name and Grade of Laboratory Officer
9. Signature
26. Typed Name and Grade of Dental Officer
27. Signature
DD Form 2322, APR 2009
Dental Laboratory Work Authorization
DD Form 2322 (Back), APR 2009
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PREVIOUS EDITION IS OBSOLETE.

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