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Customer Information
Practice Name/Organization
*
Attention
Email (for order receipt)
*
Preferred Shipping Carrier
UPS
Fedex
We use local pickup/delivery
Shipping Speed for Resupply
*
Please Select
UPS Ground
Include Supply with my Integrity Dental Driver
ASAP
2nd Day Delivery
Items Requested
Standard Prescription Pads
Please Select
1
2
3
4
5
6
7
8
9
10
0
Implant Prescriptions Pads
Please Select
1
2
3
4
5
6
7
8
9
10
Quantity of Shipping Labels
Please Select
0
3
5
10
15
20
25
Small Case Boxes (5"x4"x3")
Please Select
0
5
10
Medium Case Boxes (6.5"x5"x5")
Please Select
0
5
10
Large Case Boxes (7.5"x6"x4")
Please Select
5
10
0
Extra-Large Case Boxes (8"x8"x8")
Please Select
0
5
10
15
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