Your Contact Information

Office or Practice Name

First Name

Street Address 1

City

Postal Code

Office Phone

Your Responsibility

Last Name

Street Address 2

State

Fax

Handpiece Information Item 1
Make Serial # Type of Service

Item 2
Make Serial # Type of Service

Item 3
Make Serial # Type of Service

Item 4
Make Serial # Type of Service

Item 5
Make Serial # Type of Service

Shipping Information

	Please Send Free UPS Mailer Kit
	Prepaid UPS Label - Faxed
	Prepaid UPS Label - Emailed
	I will ship myself. (Print out the Free US Postage Paid Business Reply Label)

Additional Comments

After submitting the form, please print out two copies of this form:
1) For your records
2) To include with repair package