Having read and agreeing to comply with the above guidelines, I accept responsibility for the proper use of the WDR instruments.
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Instrument Kit Rental Application
Name of Individual or Clinic:
*
Title
*
Name of Dentist or Physician:
*
Dental / Medical License #:
*
Dental / Medical License Expiration Date:
*
-
Month
-
Day
Year
Date
State/Country of Licensure:
*
Contact Information
Email Address:
*
Confirm Email Address:
*
Phone:
*
Format: (000) 000-0000.
Alternate Phone:
*
Format: (000) 000-0000.
Trip Information
Organization's Name:
*
Name of Country (or countries) visiting:
*
Date of trip:
Start Date
-
Month
-
Day
Year
End Date
-
Month
-
Day
Year
Date instruments are needed before your trip departs:
*
-
Month
-
Day
Year
Please do not enter a date that falls on Saturday or Sunday. All shipments must be delivered Mon-Fri
Qty of Surgical Instrument Sets
*
Please Select
0
1
2
Qty of Restorative Instrument Sets
*
Please Select
0
1
2
Qty of Hygiene Instrument Sets
*
Please Select
0
1
2
Billing Information
Select one for BILLING address:
Business
Residence
Name:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Shipping Information
We are not able to ship to PO Boxes!
Shipping address is the same as the Billing address.
Select one for SHIPPING address:
Business
Residence
Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
WDR will send an email confirmation to me advising whether the kits I have requested are available for the date I specified above. I will provide credit card information to WDR after confirmation of availability is received. If payment details are not provided within five (5) business days after receiving confirmation of my reservation, the kits I have requested may be given to another team.
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