Fax: 1-203-773-9832 Phone: 1-800-246-YALE (9253) 375 Orange Street New Haven, Connecticut 06511 Web Site: www.moyaledental.com E-mail: moyaledentalinc@yahoo.com

- All instruments are serviced and back to your office in two weeks -
Please sterilize all instruments to be serviced

Print out this form and mail in with your instruments.

Retipping Services Order Form

Bill / Ship To:

Dr:

Address:

City: State: Zip:

Contact Person:

Telephone #: Fax #:

E-mail address:

VISA    |  MC   | AMEX | CHECK   (payable to: "The Moyale")

Card #:    Exp. Date:

Instrument Retipping

Instrument    Same Tip as # on Handle? Single End? Double End? Change Tip To: Quantity Cost Each Extended             $  $              $  $              $  $              $  $              $  $              $  $

TOTAL: $

SHIPPING: $

Other Services

Description Quantity Cost Extended Christensen Conversion - retipped    $25.00 $ Christensen Conversion - new    $35.00           Sharpening     $ Double Ended   $3.50 $ Single End   $2.50 $ Scissors   $7.40 $ Orthodontic Pliers   $8.40 $  TOTAL AMOUNT OF ORDER: $  SHIPPING/HANDLING: 0-60   instruments...$10.25                                  61-80  instruments...$12.25                                 81-100 instruments...$14.25 $ TOTAL $

NOTE: If your instruments are not retippable, we will send you a replacement for an additional $16.99.