Dental Lab Exclusion Request Form
Submit a request to exclude an item or service from dental lab operations. Please complete all fields accurately to ensure timely processing.
Requester Full Name
*
First Name
Last Name
Requester Email Address
*
example@example.com
Department or Clinic
*
Please Select
Orthodontics
Prosthodontics
Oral Surgery
Periodontics
Pediatric Dentistry
General Dentistry
Other
Request Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Excluded Item or Service
*
Please Select
Crown Fabrication
Bridge Fabrication
Denture Processing
Implant Restoration
Orthodontic Appliance
Custom Tray
Other
Exclusion Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Exclusion
*
Quality Issue
Service Delay
Cost Concern
Vendor Performance
Process Change
Other
Description of Exclusion Request
*
Operational Notes for Processing
Lab Contact Person (if applicable)
Submit Request
Should be Empty: