Cassette Warranty Registration

Personal data

Purchase First Name

Purchase Last Name

Practice name

Practice address *

Indirizzo

City/Town

ZIP/Postal Code

Paese

Primary email

Primary Phone

Fax Number (optional)

Cassette type	Quantity	Operazioni
Cassette type	Quantity

Date

Sterilizer	Model	Operazioni
Sterilizer	Model

Ultrasonic-Automated Washer	Model	Operazioni
Ultrasonic-Automated Washer	Model

Dentists

Hygienists

Assistants

Dental Speciality

Other Dental Speciality

Dealer Name

Dealer City

Other Dealer

I authorise the prossessing of personal data, in compliace with DL 196/2003

I'd like to receive updates on IMS products, Educational Materials