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Coltolux Comfort

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Residing Country*

United States

Canada

I Would Like to*

Place an Order through my Dealer

Request an in Office Demo

Request a Lunch & Learn

Request Contact by Local Rep

We're pleased to hear of your interest in our Lunch & Learn sessions. You will receive a follow-up email shortly from your local COLTENE representative.

You will be able to select your preferred U.S. or Canadian dealer, who will then process and fulfill your order.

Contact Information

Practice Name*

National Physician ID No.*

(required for US doctors)

Name*

Prefix First Last

Phone*

Email*

Order Selection and Preferred Dealer

Will your order include multiple part numbers?*

Yes

No

Product Selection*

Quantity*

Product Selection*

Quantity*

Product Selection

Quantity

Preferred Dealer*

Delivery Address

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Street Address Address Line 2 City State ZIP Code

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Street Address Address Line 2 City Province Postal Code

Billing Address

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Street Address Address Line 2 City Province Postal Code

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Street Address Address Line 2 City State ZIP Code

How Did You Learn About COLTENE?

Please Share How You Learned About Us

Would You Mind Sharing the Name of Your Distributor?

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TERRITORY / REG. MGRS (USA)

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TERMS

Terms*

I agree to the terms of service

YOUR ORDER IS BILLED BY YOUR DEALER. Prices, taxes, and shipping will be determined and billed by your preferred dealer.

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330.916.8800

235 Ascot Parkway
Cuyahoga Falls, OH 44223

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