At this time, we are unable to fulfill international requests. *Indicates required field. First Name: * Last Name: * Email: * Confirm Email: * Company: * Address: * City: * State: *Zip:    * Country: USA * Phone: * Fax:   Practice: SELECT General Ortho Endo Perio Pedo Other # of Operatories:  #of Hygienists : # of Prophy Cleanings Per Week:   Disposable Prophy Angle Samples Contra Disposable Long Cup Turbo Plus, Turbo Plus LF Classic Disposable Long Cup Traditional Web LF, Turbo, Pointed Polisher LF Elite Flex™ Includes 3 Contra and 3 Classic Elite Extend Flex™ Includes 3 Contra and 3 Classic Elite Original™ Includes 3 Contra and 3 Classic Pointed Polisher Includes 6 Classic Prophy Brushes Includes 6 classic prophy brushes Prophy Cup Samples Elite Flex™ Cups - latex-free Elite Extend Flex™ Cups - latex-free Elite Original™ Cups - latex-free Pointed Polishers - latex-free Additional Product Samples/Literature D-Lish Prophy Paste Moisture Control (Surg-O-Vac, Vent-O-Vac, Dri-Aid) Disclosing Agents HO Bands Oral Health Educational Brochure Country: *

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