Dental Health 2016 Catalog

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 Iso Form Crowns ™

Molar Crowns__________Set

Bicuspid Crowns__________Set

3M Polycarbonate Crown

__________Set

3M Gold Anodized Crown

Molar Crowns No.__________Set

3M Pediatric Strip Crown Forms__________Set

CROWNS

203

Order by

800-626-2163

www.dhpionline.com

Fax: 888-681-5088