Full Arch Agreement

Dr's Name:*
Billing Address:*

Property Number and Street Name

Locality / Village / Hamlet (Optional)

Town / CityCounty (Optional)

PostcodeCountry
Is the shipping address the same as the billing address?*

YesNo
Shipping Address:*
Shipping Address:*

Property Number and Street Name

Locality / Village / Hamlet (Optional)

Town / CityCounty (Optional)

PostcodeCountry
Number of Boxes Required:*
Requested Date of Delivery: *

DayMonthYear
Surgery Date:*

DayMonthYear
* The maximum amount of time a Full Arch box can be sent out prior to the surgery date must not exceed 48-hours.
Collection Date:*

DayMonthYear
* Collections will be arranged a day after the surgery date. We use DPD for this service and they will collect anytime from 9:00am – 6:00pm. Please ensure the parcel is ready to be collected. Failure will result in a £10.50+VAT charge for collection and any subsequent missed collections. If the Full Arch Box is required for a longer period, please contact fab@osstemuk.com.
Email:*
example@example.com
Dialing Code:*
Phone Number:*
Phone Number:*
Additional Details:
Territory Manager:*
If you are unsure who your Territory Manager is, you can find out here.
Title: *
Name:*
Date:*

DayMonthYear
Signature:*

Clear
* Please ensure that the full arch box is returned in the same condition in which it was received — fully intact and packaged in the two heavy, reinforced boxes. To avoid delays in the issuance of credit notes, kindly ensure that the stock list included in the box is completed accurately, clearly indicating all items used.
Please verify that you are human*
Should be Empty: