Handpiece
Trading Post - Repair
18627 Brookhurst St. #351
Fountain Valley, CA 92708
Phone: 1-800-445-6719
Fax: 1-714-444-4497 |
Please print a copy of this form.
Fill out the information below and mail with the
equipment to be repaired.
This is your return address, please print clearly.
Please sterilize all Instruments.
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Doctor:
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Address:
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City/State/Zip:
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Phone:
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METHOD OF PAYMENT: (Circle one)
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Ship COD
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Visa
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MasterCard
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AmEx
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Discover
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Credit
Card # |
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Expiration Date |
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Credit
Card Statement Zip Code:
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Signature:
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Handpiece |
Serial
No. |
Problem |
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