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WORK ORDER:
*
Indicates required field
Practice Name
*
Primary Contact
*
First
Last
Phone
*
Address
*
Line 1
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City
State
Zip Code
Country
Email
*
Handpiece Type
*
High Speed
Slow Speed
Electric
Surgical
Other Equipment (Describe below)
Handpiece Type
*
None
High Speed
Slow Speed
Electric
Surgical
Other Equipment (Describe below)
Choose One
*
Call With an Estimate
Just Fix It!
Manufacturer
*
Midwest
Kavo
Star
NSK
Kinetics
Lynx
Other
Manufacturer
*
None
Midwest
Kavo
Star
NSK
Kinetics
Lynx
Other
Payment Method
*
Bill to my account
Charge my MC/Visa
Qty
*
1
2
3
4
5
6+
Qty
*
0
1
2
3
4
5
6+
Serial Numbers/Problem
*
Please list the product serial number, hit return and provide a brief description of the problem on the line below. Repeat for each item.
Delivery Options
*
I have what I need to send in my equipment. It's on the way!
I would like to request pick up/drop off service.(Complimentary within 10 mi radius of 07970)
I have some questions before sending in my equipment. Please call me.
Comment/Special Requests
*
Click "Print" button prior to submitting if you'd like a hard copy for your files. (You should also have a copy in your email "Sent Items" folder.)
After hitting "Submit" below, you will be taken directly to a link where you will have the option to print out a complimentary mailing label. That page also serves as confirmation that your work order has been sent. Thank You!!!
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