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3M PREFABRICATED CROWN ORDER FORM
Name___________________________________________________________________
Phone _______________________________
Address ____________________________________________________________________________________________________________
City ____________________________________________________
State_____________
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.
Fax: 888-681-5088
or call your Dental Health Products Account Manager at
800-626-2163
3M Stainless Steel Primary Molar
__________Set
3M Unitek ™ Stainless Steel Primary Molar
__________Set
3M Unitek ™ Stainless Steel Primary Anterior
__________Set
3M Stainless Steel Permanent Molar
__________Set
3M Unitek ™ Stainless Steel Permanent Molar
__________Set
3M Unitek ™ Stainless Steel Bicuspid
__________Set
CROWNS
202
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