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  • Customer Information Form

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    rustamsh2015
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    This document is a customer information form for Docere Dental to purchase an iTero Element Intraoral Scanner from Align Technologies. It requests contact information for Docere Dental such as practice name, address, phone number, email, and website. It also requests information such as the scanner serial number and wand serial number. The form is to be completed and returned to Align Technologies.

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    This document is a customer information form for Docere Dental to purchase an iTero Element Intraoral Scanner from Align Technologies. It requests contact information for Docere Dental such as practice name, address, phone number, email, and website. It also requests information such as the scanner serial number and wand serial number. The form is to be completed and returned to Align Technologies.

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    © All Rights Reserved
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    4 views1 page

    Customer Information Form

    Uploaded by

    rustamsh2015
    This document is a customer information form for Docere Dental to purchase an iTero Element Intraoral Scanner from Align Technologies. It requests contact information for Docere Dental such as practice name, address, phone number, email, and website. It also requests information such as the scanner serial number and wand serial number. The form is to be completed and returned to Align Technologies.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    iTero® Element™ Intraoral Scanner – Customer Information Form

    Complete Form and Return to Align at: iTeroPartners@aligntech.com

    CUSTOMER INFORMATION

    Docere Dental
    Practice Name (“Customer”) Date
    Docere Dental
    Doctor(s) Name(s)
    Dr. Javokhir Abdujabborov
    Primary Office Contact
    Nukus street 31/8 (#1587503)
    SHIP TO Address
    Tashkent 10000 Uzbekistan
    City Post Code Country

    BILL TO Address (if different)


    Tashkent 10000 Uzbekistan
    City Post Code Country
    +998998628020
    Telephone Number Fax Number
    dr.javakhir@gmail.com
    Email Website

    c22471975
    Office Hours ClinID (if Invisalign)

    WOA2019W33A027 60949
    Scanner S/N Wand S/N

    Lab Partner (1)) Name and Address

    WWW.ITERO.COM

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