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Purchase min of $2,999 in Qualifying Impression Material, receive duomix II at no charge
Promotion Valid Until March 31st, 2024 in Canada ONLY
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
Attach Invoice
*
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