Form

Dentist's Email*

Req'd by the FDA.

Must be the Dentist's email.

If this is purely a Dealer Distribution Center overstock return, please visit https://share.hsforms.com/1T-TqFmwYQvqGW-BBpdgWwwbypc5

Requestor's email*

Status updates and instructions will be sent here:

Salutation*

Dentist's First name*

Dentist's Last name*

Specialty

Dentist, Periodontist, Oral Surgeon, etc

Dental Office Phone number*

Street address*

City*

State/Region*

Postal code*

Purchase Date*

Month/Day/Year

PO #

Purchased through which Distributor?*

Item SKU(s) being returned*

Quantity to Return/Exchange*

Quantity, Notes or Explanation?

Reason for return, product comments, how many items you want to return etc

File upload

If you want to include photos, scans, pdfs, etc