FREE GOODS & REBATES "*" indicates required fields Follow the field instructions below. Select Your Country* United States Canada Full Name* Prefix Dr.MissMr.Mrs.Ms.Prof.Rev. First Last Phone Number*Email Address* Practice Name*NPI Number*Delivery AddressDelivery Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Delivery Address* Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Are you submitting more than one promo code?* Yes No Are you redeeming these promos with more than 1 dealer?* Yes No How many dealers are you submitting today?*Select23Up to 3 submissions are allowed for now. If you have more than 3, please submit them in intervals. If this request becomes frequent, we'll happily update our form.Add Dealer(s) InformationSelect Dealer Name*Please Select3Z DENTALACME DENTALAM-TOUCH DENTALATLANTA DENTALBENCO DENTALBURKHART DENTALCAROLINA DENTALCENTRAL DENTALDARBY DENTALDAVIS DENTALDC-DENTAL (USA-VERSION)DDS DENTALDENTAL BRANDSDENTAL CITYDHPDIATECHFRONTIER DENTALGOETZE DENTALHEALTHCARE SUPPLY CORPORATIONHENRY SCHEIN CANADAHENRY SCHEIN USAIQ DENTALJOHNSON AND LUND DENTALK-DENTALKINGS TWO DENTALLAB DEPOTMEDISELECT DENTALMIDWAY DENTALMIDWEST DENTALMS DENTALNASHVILLE DENTALNEWARK DENTALNORTHERN SURGICALNOWAKOC DENTALPATTERSON DENTALPATTERSON DENTAL CANADAPEARSON DENTALPREFERRED DENTAL SERVICESPURE LIFE DENTALSAFCO CANADASAFCO DENTALSCOTT'S DENTALSINCLAIR DENTALSKY DENTALSUPPLYDOCTOP QUALITY DENTALTRISTATE DENTALVALUEMEDYOUNGS DENTALInvoice Number*Date of Purchase* MM slash DD slash YYYY 2 DealersSelect Dealer 1*Please Select3Z DENTALACME DENTALAM-TOUCH DENTALATLANTA DENTALBENCO DENTALBURKHART DENTALCAROLINA DENTALCENTRAL DENTALDARBY DENTALDAVIS DENTALDC-DENTAL (USA-VERSION)DDS DENTALDENTAL BRANDSDENTAL CITYDHPDIATECHFRONTIER DENTALGOETZE DENTALHEALTHCARE SUPPLY CORPORATIONHENRY SCHEIN CANADAHENRY SCHEIN USAIQ DENTALJOHNSON AND LUND DENTALK-DENTALKINGS TWO DENTALLAB DEPOTMEDISELECT DENTALMIDWAY DENTALMIDWEST DENTALMS DENTALNASHVILLE DENTALNEWARK DENTALNORTHERN SURGICALNOWAKOC DENTALPATTERSON DENTALPATTERSON DENTAL CANADAPEARSON DENTALPREFERRED DENTAL SERVICESPURE LIFE DENTALSAFCO CANADASAFCO DENTALSCOTT'S DENTALSINCLAIR DENTALSKY DENTALSUPPLYDOCTOP QUALITY DENTALTRISTATE DENTALVALUEMEDYOUNGS DENTALDealer 1: Invoice NumberDealer 1: Date of Purchase* MM slash DD slash YYYY Select Dealer 2*Please Select3Z DENTALACME DENTALAM-TOUCH DENTALATLANTA DENTALBENCO DENTALBURKHART DENTALCAROLINA DENTALCENTRAL DENTALDARBY DENTALDAVIS DENTALDC-DENTAL (USA-VERSION)DDS DENTALDENTAL BRANDSDENTAL CITYDIATECHDHPDIATECHFRONTIER DENTALGOETZE DENTALHEALTHCARE SUPPLY CORPORATIONHENRY SCHEIN CANADAHENRY SCHEIN USAIQ DENTALJOHNSON AND LUND DENTALK-DENTALKINGS TWO DENTALLAB DEPOTMEDISELECT DENTALMIDWAY DENTALMIDWEST DENTALMS DENTALNASHVILLE DENTALNEWARK DENTALNORTHERN SURGICALNOWAKOC DENTALPATTERSON DENTALPATTERSON DENTAL CANADAPEARSON DENTALPREFERRED DENTAL SERVICESPURE LIFE DENTALSAFCO CANADASAFCO DENTALSCOTT'S DENTALSINCLAIR DENTALSKY DENTALSUPPLYDOCTOP QUALITY DENTALTRISTATE DENTALVALUEMEDYOUNGS DENTALDealer 2: Invoice NumberDealer 2: Date of Purchase* MM slash DD slash YYYY 3 DealersSelect Dealer 1*Please Select3Z DENTALACME DENTALAM-TOUCH DENTALATLANTA DENTALBENCO DENTALBURKHART DENTALCAROLINA DENTALCENTRAL DENTALDARBY DENTALDAVIS DENTALDC-DENTAL (USA-VERSION)DDS DENTALDENTAL BRANDSDENTAL CITYDHPDIATECHFRONTIER DENTALGOETZE DENTALHEALTHCARE SUPPLY CORPORATIONHENRY SCHEIN CANADAHENRY SCHEIN USAIQ DENTALJOHNSON AND LUND DENTALK-DENTALKINGS TWO DENTALLAB DEPOTMEDISELECT DENTALMIDWAY DENTALMIDWEST DENTALMS DENTALNASHVILLE DENTALNEWARK DENTALNORTHERN SURGICALNOWAKOC DENTALPATTERSON DENTALPATTERSON DENTAL CANADAPEARSON DENTALPREFERRED DENTAL SERVICESPURE LIFE DENTALSAFCO CANADASAFCO DENTALSCOTT'S DENTALSINCLAIR DENTALSKY DENTALSUPPLYDOCTOP QUALITY DENTALTRISTATE DENTALVALUEMEDYOUNGS DENTALDealer 1: Invoice NumberDealer 1: Date of Purchase* MM slash DD slash YYYY Select Dealer 2*Please Select3Z DENTALACME DENTALAM-TOUCH DENTALATLANTA DENTALBENCO DENTALBURKHART DENTALCAROLINA DENTALCENTRAL DENTALDARBY DENTALDAVIS DENTALDC-DENTAL (USA-VERSION)DDS DENTALDENTAL BRANDSDENTAL CITYDHPDIATECHFRONTIER DENTALGOETZE DENTALHEALTHCARE SUPPLY CORPORATIONHENRY SCHEIN CANADAHENRY SCHEIN USAIQ DENTALJOHNSON AND LUND DENTALK-DENTALKINGS TWO DENTALLAB DEPOTMEDISELECT DENTALMIDWAY DENTALMIDWEST DENTALMS DENTALNASHVILLE DENTALNEWARK DENTALNORTHERN SURGICALNOWAKOC DENTALPATTERSON DENTALPATTERSON DENTAL CANADAPEARSON DENTALPREFERRED DENTAL SERVICESPURE LIFE DENTALSAFCO CANADASAFCO DENTALSCOTT'S DENTALSINCLAIR DENTALSKY DENTALSUPPLYDOCTOP QUALITY DENTALTRISTATE DENTALVALUEMEDYOUNGS DENTALDealer 2: Invoice NumberDealer 2: Date of Purchase* MM slash DD slash YYYY Select Dealer 3*Please Select3Z DENTALACME DENTALAM-TOUCH DENTALATLANTA DENTALBENCO DENTALBURKHART DENTALCAROLINA DENTALCENTRAL DENTALDARBY DENTALDAVIS DENTALDC-DENTAL (USA-VERSION)DDS DENTALDENTAL BRANDSDENTAL CITYDHPDIATECHFRONTIER DENTALGOETZE DENTALHEALTHCARE SUPPLY CORPORATIONHENRY SCHEIN CANADAHENRY SCHEIN USAIQ DENTALJOHNSON AND LUND DENTALK-DENTALKINGS TWO DENTALLAB DEPOTMEDISELECT DENTALMIDWAY DENTALMIDWEST DENTALMS DENTALNASHVILLE DENTALNEWARK DENTALNORTHERN SURGICALNOWAKOC DENTALPATTERSON DENTALPATTERSON DENTAL CANADAPEARSON DENTALPREFERRED DENTAL SERVICESPURE LIFE DENTALSAFCO CANADASAFCO DENTALSCOTT'S DENTALSINCLAIR DENTALSKY DENTALSUPPLYDOCTOP QUALITY DENTALTRISTATE DENTALVALUEMEDYOUNGS DENTALDealer 3: Invoice NumberDealer 3: Date of Purchase* MM slash DD slash YYYY Upload your invoice(s) and input promo code(s)Upload your invoice(s) here* Drop files here or Select files Max. file size: 5 MB. Please enter the promo that matches your invoice purchase*Start typing your promo codePROMO DESCRIPTION 12nd Promo CodeStart typing your promo codePROMO DESCRIPTION 23rd Promo CodeStart typing your promo codePROMO DESCRIPTION 3 EARN AN ADDITIONAL $50! 150 + 50 = $200 By taking a moment to participate in our brief new product survey, you can share valuable feedback that means so much to us.Do you wish to earn an additional $50 by participating in our survey?* Yes! I want to earn an additional $50!!! No. I'll Pass on this opportunity! OPTIONAL. You'll be redirected after you submit your redemption(s). Brief SurveyJob Title*Please SelectDentistHygienistDental AssistantOffice ManagerFront Desk ReceptionistInsurance CoordinatorTreatment CoordinatorScheduling CoordinatorSterilization TechnicianPatient Care CoordinatorBilling SpecialistDealer RepresentativeYou may skip this survey and submit the form How would you rate your overall satisfaction with the product?*Very DissatisfiedDissatisfiedNeutralSatisfiedVery Satisfied How does this product compare to similar products you’ve used?* Better Equal Worse On a scale of 1-10, how likely are you to recommend this product to a friend or colleague?*12345678910 Do you have a preference for where your dental supplies are made?* USA Switzerland No preference Additional Comments (optional)This field is hidden when viewing the formTERRITORY / REG. MGRS (USA)This field is hidden when viewing the formGET ZIP CODE (USA)(searches google sheet)This field is hidden when viewing the formTerritory Mgr. (USA)(Dynamic Population)This field is hidden when viewing the formRegional Mgr. (USA)(Dynamic Population)This field is hidden when viewing the formTerritory Mgr. Email (USA)(Dynamic Population)This field is hidden when viewing the formTerritory Mgr. Email (USA)(Dynamic Population)This field is hidden when viewing the formTERRITORY / REG. MGRS (CA)This field is hidden when viewing the formGET ZIP CODE (CA)(searches google sheet)This field is hidden when viewing the formTerritory Mgr. (CA)(Dynamic Population)This field is hidden when viewing the formRegional Mgr. (CA)(Dynamic Population)This field is hidden when viewing the formTerritory Mgr. Email (CA)(Dynamic Population)This field is hidden when viewing the formTerritory Mgr. Email (CA)(Dynamic Population)Unable to submit. Your free goods code is past its redemption date.