Screw-Retained Restorations - Com-Dental

Ordering Form
Copy and fax completed form to BIOMET 3i Customer Service at 561-776-1272.
Patient Name:
Existing Customer: ■ Yes
■ No
Billing Information
Name Account Number Date Order Placed
Street Address/Suite # Order Placed By P.O. Number
City State Zip Code Phone (Include Area Code) Fax (Include Area Code)
Shipping Information
Payment Method
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Credit Card (please circle card)
Name
Visa MasterCard American Express
Card No. ___________________________
Street Address/Suite #
■
Exp. Date ___________________________
COD
■ Bill Net 30
City State Zip Code
Shipping Method (check one)
■ Economy
■ Priority Overnight
■ Standard Overnight ■ Saturday Delivery ■ UPS
Item Numbers Quantity Description
Thank you for your patronage! For further assistance, call BIOMET 3i Customer Service at 800-342-5454.