DED PICK UP REQUEST FORM
A driver will be there soon !!!
Dental Office:
Name of Dental Practice
Doctor's name:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone Number
Please enter a valid phone number.
Pick up Date & Time
*
PLEASE CHOOSE PICK UP DEPARTMENT
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REMOVABLE DEPARTMENT
Dentures, Partial Dentures, Custom Trays, Bite Block, Set ups, Finish and process, Flexible Partials and metal frames too.
$
Free
Quantity
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Crown and Bridge Department
PFM, PFZ, Full Zirconia , Full Cast Crowns,
$
Free
Quantity
1
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SAME DAY RAPAIR or Relines
Same Day Service Request
$
Free
Quantity
1
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Dr. Notes
Example. Need Bags
RX picture (Important)
Browse Files
Drag and drop files here
Choose a file
send us a picture of the case. We receive hundreds of cases. keeping a digital copy will be better for your records and ours.
Cancel
of
Case Picture
Browse Files
Drag and drop files here
Choose a file
Send us a picture of the case. We want to make sure our driver bring exactly what you packed for us.
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of
Pick up, Ready!
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