For Dealers


If you are a representative from a dental dealer and would like to place an order, please complete the order form.

	Quarterly Frequency 1 Badge and 1 Report per Quarter (4/yr)
	Monthly Frequency 1 Badge and 1 Report per Quarter (12/yr)
	Fetal Monthly Frequency 1 Badge and 1 Report per Month for 7 Months
	CPR™ Cosmetic Polishing Restorative 100/jar	Qty
	Diamond Glaze Polish	Qty
	Rad-Badge™ High Tech USB Monitoring Service 1 Year USB X-Ray Monitoring Service: Immediate dose report access from your computer, at your convenience, any time, no more shipping.	Qty
	Formaldehyde Vapor Monitoring Badge	Qty
	Glutaraldehyde Vapor Monitoring Badge	Qty
	Mercury Vapor Monitoring Badge	Qty
	Nitrous Oxide Vapor Monitoring Badge	Qty
Dealer / Rep. Name	*
Dealer / Rep email	* (e-mail necessary for order confirmation)
Rep / PO #:	*
	Shipping Address
DR.	*
Address	*
City	*
ST	*
ZIP	*
Phone	*
Fax
Email	*
PLEASE PROVIDE BADGES FOR THESE EMPLOYEES PRINT FIRST, MIDDLE & LAST NAME
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	Send these badges ASAP for this quarter
	Send badges beginning next quarter
	* orders placed after 6th week of calander quarter will be shipped the next calander quarter
As REP / DEALER, by submitting this form you hereby authorize ICCARE to process your order.