Instrument Repair/Retipping Ticket
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Received. Thank you!
Please type your TICKET NUMBER here. Your ticket number is today's date and the last four digits of your practice phone number (YY-MMDD-####)*
Practice Name*
Contact Name*
Email*
Practice Phone Number*
Street Address*
City*
Postal Code*
Province*
Please Select
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Number of Luxators/Elevators I am sending*
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Number of Scalers/Curettes I am sending*
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Number of Periosteal Elevators I am sending*
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Number of Root Tip Picks I am sending*
Please Select
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Number of Bone Curettes I am sending*
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Number of Other instruments I am sending*
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Number of needle drivers I am sending*
Please Select
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Please note any concerns (if any) regarding your instruments.
I understand that my completed form will be emailed to me and that I must print 2 copies of my form results, one to include with my shipment and one for my records.*
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