Evaluation Product Request

Evaluation Product Request
Customer Information
Name*

First NameLast Name
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Work Email*
example@example.com
Personal Email
Dental license #/State*
Current System*
Product
Product Name/Description
Tip size
mm length
Product Name/Description
Tip Size
mm length
Product Name/Description
Tip size
mm length
Total amount
By accepting any no-charge sample or evaluation product, you agree that you will not charge, or seek reimbursement by any third party, including any federal or state program (e.g., Medicare, Medicaid, Tricare of Children’s Health Insurance Program), for the use of the products.

Supply granted to sample purposes is not to exceed a 90-day supply or lesser time necessary to sufficiently evaluate the product.

Acknowledged and Agreed By:
Name*

First NameLast Name
Title*
Signature*

Clear
Date*

MonthDayYear
Date
Nexternal Order
Nexternal Order Number
Should be Empty:

Customer Information