* All fields are required Facility Name Contact Name Street Address City State ---AKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code Telephone Email Address Model Purchased (Item 1) Please SelectAir Compressed High Speed Dental StationCorix X-Ray GeneratorDTX Digital Dental Imaging SystemOther Serial Number Model Purchased (Item 2) Please SelectAir Compressed High Speed Dental StationCorix X-Ray GeneratorDTX Digital Dental Imaging SystemOther Serial Number Model Purchased (Item 3) Please SelectAir Compressed High Speed Dental StationCorix X-Ray GeneratorDTX Digital Dental Imaging SystemOther Serial Number Model Purchased (Item 4) Please SelectAir Compressed High Speed Dental StationCorix X-Ray GeneratorDTX Digital Dental Imaging SystemOther Serial Number Note: If you are registering more than 4 items, please submit this form, refresh, and complete another form. Date Purchased Distributor purchased from ---Henry Schein Animal HealthMidwest Veterinary SupplyMWI Veterinary SupplyAnimal Health InternationalVictor Medical CompanyPatterson Veterinary SupplyWestern Medical Supply, Inc.Miller Veterinary Supply Co., Inc.Veterinary Anesthesia SystemsVeterinary Dental Supplies Upload invoice here
