2017 MEDINOL DENTAL TARIFFS ORDER FORM
Your Name
*
Practice's Name
*
Phone
*
Email
*
How would like to receive the 2017 DentalTariff Update
*
Do it for me via remote (R845)
Send link via Email (R795)
Choice of update:
*
Discovery-based Rates
GEMS-based Rates
DENIS-based Rates
Prosthedontist
Date on which your rooms re-open?
*
Date Format: DD slash MM slash YYYY
Confirm
*
I am authorised to order on behalf of the practice
