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Palodent Plus Ring Trade Up- Buy 2 -Trade 1 - Get 1
Promotion Valid Until September 30th, 2024 in Canada ONLY. Must redeem by October 31, 2024.
Customer Information
Contact Name
*
First Name
Last Name
Customer Email
*
example@example.com
Practice Name
*
Practice Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Customer Phone Number
*
Dentsply Sirona Account Number
SalesForce SF#
Dentsply Sirona Chairside Specialist
Please Select
Jean Crawshaw -BC
Joanne Hovey -BC
Michelle Boucher - BC
Jennifer Reyes - AB
Nicolette Tessier -AB
Sheena Fiander-AB
Kristy Charlton -SK
Kylee Zylberman -MB
Lisia Malcolm -ON
Manny Gill -ON
Marc Pelletier -ON
Michael Hannan -ON
Paul Khazzaka -ON
Tom Giftakopoulos -ON
Tabitha Thompson -ON
Diane Bellemare -QC
Martin Durand -QC
Pier-Luc Boucher - QC
Rima Ambaraghassi -QC
Natalie Hayes -NS/NB/PEI/NFLD
Authorized Distributor
Please Select
Patterson Dental
Henry Schein
Sinclair Dental
K-Dental
Other - please specify in comments box
Invoice date
*
-
Month
-
Day
Year
Date
Certification
*
I certify that the trade-in ring has been traded in, removed from office, and disposed of properly.
Attach Invoice
*
Browse Files
Drag and drop files here
Choose a file
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of
Attach Picture of Old Ring for Trade-In
*
Browse Files
Drag and drop files here
Choose a file
Submit your old rings to your local Dentsply Sirona Rep or dealer rep. Your Dentsply Sirona rep will follow-up with an estimated delivery date for your new rings.
Cancel
of
How many Trade-ins are you doing? Each refill has 2 rings/pack.
Please Select
1 Trade-in (2 rings)
2 Trade-ins (4 rings)
3 Trade-ins (6 rings)
If more than 1 trade-in, add details for extra refill rings in Comments below.
Select which size of rings for free
1x659760
1x659770
Comments:
Print Form
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