2022 Imaging Promotion Redemption Form

2022 Promotion Redemptions

November to December 2021 redemptions? Visit: https://form.jotform.com/213015831371143
What Promotion Are You Here To Redeem?*

Welcome to the Upgrade Your Diagnostic Capabilities with Axeos Program!

Once you have completed and submitted this form, make sure that you box up the appropriate components and return them to Dentsply Sirona. You'll need to include the Packaging Form and if you are near a printer, a copy of your promotional form confirmation email. Here are resources for you to help finalize this program:
- Axeos Upgrade Program Packaging Form
  Please reference the Program's full Terms and Conditions if you have additional questions.
For Trade-Ins - this is the workflow for how to submit/what needs to be included...

1) Please upload a picture of the extraoral device
2) Please upload a picture of the serial number on the device

3) Safely remove the unit serial number label or plate from the unit and either stick to the return packing form, or place it in the envelope/box being shipped back.

Shipping...

Safely remove the unit serial number label or plate from the unit (Note: Dentsply Sirona extraoral imaging device serial number stickers are typically located on the back of the column in the bottom right). If it’s a sticker, stick it to the Dentsply Sirona Axeos Upgrade Program return packaging form. Complete the Dentsply Sirona Axeos Upgrade Program return packaging form.

Ship to:
2022 Axeos™ Upgrade Program
Dentsply Sirona 11000 S. Commerce Blvd., Ste K Charlotte, NC 28273
What Axeos Upgrade Program Are you Redeeming?*

$15,000 Trade In Credit (Promo Code: TRADEIN - 15K-22)$10,000 Equipment Owner Appreciation (Promo Code: CEREC - 10K-22)
Dentsply Sirona Customer Salesforce ID # (SFID)
This number should start with SF and be 9 characters long (e.g. SF1234567)
Customer Name*

First NameLast Name
Business Name*
Phone Number*

Area CodePhone Number
Customer E-mail*
Joe.Smith@example.com
Customer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dealer Partner*
Order Date*

MonthDayYear
Date
Dealer Employee Name*

First NameLast Name
Dealer Employee Completing Form E-mail*
Joe.Smith@example.com
Invoice # or Internal Order #*
Proof of Axeos Purchase*

Browse Files
Please attach a copy of your invoice OR signed customer order. Acceptable file types include JPG, GIF, PNG, or PDF Cancelof
Dentsply Sirona Field Rep

First NameLast Name
Dentsply Sirona Field Rep E-mail
Joe.Smith@dentsplysirona.com
- Picture of Extraoral Device Serial # for the unit that is being traded-in*
  
  Browse Files
  
  Cancelof
- Proof of Equipment Ownership: Original Invoice, Dentsply Sirona Customer Service Email Confirmation, SIROforce/DSCRM screen grab, or CEREC Club/Schick Club Invoice (from/within the past 60 Days). *
  
  Browse Files
  Qualifying devices: CEREC MC X, CEREC MC XL, PRIMEMILL, Omnicam DI, CEREC Omnicam, Primescan DI, CEREC Primescan, Schick AE, Schick 33, and Schick Elite. Cancelof
- Picture of the Cerec or Schick Serial #*
  
  Browse Files
  Qualifying devices: CEREC MC X, CEREC MC XL, PRIMEMILL, Omnicam DI, CEREC Omnicam, Primescan DI, CEREC Primescan, Schick AE, Schick 33, and Schick Elite. Cancelof

Welcome to the Equipment Ownership submission page for our Dentsply Sirona CBCT Level Up Promotion!

This page is used by dealer procurement specialists to submit proof of equipment ownership for customers participating in our Dentsply Sirona Level-up promotion. Please fill in all sections of this form, upload the proof of equipment ownership document (one item/file), and submit it. Accepted proof of ownership documents include:

· Original qualifying device invoice as stated above

· Active Club Membership invoice showing active membership in the past 60 days – this can be CEREC Club, 3D Club, or Schick Club

· SIROforce or DSCRM screengrab showing the qualifying device tied to their account (DS Sales Team)

· Dentsply Sirona Salesforce.com screen grab showing the device was purchased on the customer’s account (DS Sales Team)

Upon completion, you will receive a confirmation email that should be kept for your records. It is important that this be kept as proof of submission when it comes time for dealer margin true-up. Check your JUNK folder if you don't receive a confirmation email within five minutes of making a submission.

You can review the terms and conditions for this promotion here.
Dealer Information Section

Note: The email address in this section will receive the submission confirmation email.
Dealer*
Order Date*

MonthDayYear
Date
Dealer Employee Name*

First NameLast Name
Dealer Employee Completing Form E-mail*
Joe.Smith@example.com
Customer Information Section

Complete this section with the customers information and provide the proof of equipment ownership document.
Dentsply Sirona Customer Salesforce ID# (SFID)
This number should start with SF and be 9 characters long (e.g. SF1234567)
DS CBCT Device Purchased*
Invoice # or PO # of DS CBCT Device*
DS CBCT Invoice or PO*

Browse Files
Please attach the invoice or PO for the purchased DS CBCT device. Acceptable file types include JPG, GIF, PNG, or PDF Cancelof
Business Name*
Customer Name*

First NameLast Name
Customer E-mail*
Joe.Smith@example.com
Phone Number*

Area CodePhone Number
Customer Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Proof of Equipment Ownership

Browse Files
*Optional: Upload a Picture (including Serial Number) of required current Dentsply Sirona equipment. Acceptable file types include JPG, GIF, PNG, or PDF Cancelof
Existing Unit (Currently Own) Serial Number*
Existing Unit (Currently Own) model*
Dentsply Sirona Field Sales Information

This section will send a confirmation email to the Dentsply Sirona Imaging sales representative that supported the customer sale. Please note that we need the customers Dentsply Sirona Salesforce ID # for tracking purposes. You can get this from the local Dentsply Sirona Imaging sales representative.
Dentsply Sirona Customer Salesforce ID # (SFID)
This number should start with SF and be 9 characters long (e.g. SF1234567).
Dentsply Sirona Field Rep

First NameLast Name
Dentsply Sirona Field Rep E-mail
Joe.Smith@dentsplysirona.com

Welcome! Our Build Your Own Cone Beam program does not use this portal. Please follow the specific program steps by dealer listed below:

Patterson Dental

Henry Schein Dental
Should be Empty:

Cephalometric Arm Shipping Location

Heliodent Shipping Location

Dealer Information Section

Customer Information Section

Dentsply Sirona Field Sales Information