2015-2016 Dental Reference Guide

3M PREFABRICATED CROWN ORDER FORM

Name___________________________________________________________________

Phone _______________________________

CROWNS

Address ____________________________________________________________________________________________________________

City ____________________________________________________ Zip __________________________ Instructions: This order form is formatted the same as the 3M crown kit drawers to allow for easy ordering. Fill in spaces with the number of refill boxes for each size. If there are two sizes in a space, circle the appropriate number. Refill boxes contain 5 crowns. State_____________

Fax: 888-681-5088 or call your Dental Health Products Account Manager at 800-626-2163

www.dhpionline.com

Fax: 888-681-5088

Order by 800-626-2163

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