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Request a Service Call

Request a Service Call

Complete and submit the form below to request additional information.

Returning customers, login to auto-fill this form.

Note: required fields are denoted with an asterisk(*).

Mailing Address:
Office NickName:
*Title:
First Name:
Middle Initial:
Last Name:
*E-mail Address:
*Address Line 1:
Address Line 2:
Address Line 3:
*City:
*State/Province/Region:
*ZIP/Postal Code:
Enter 00000 if a ZIP/Postal Code is not applicable.
*Country:
*Telephone Number: numbers only, 10 characters min
Telephone Extension:
Mobile Number: numbers only
Other Information
*Type of Equipment that
needs to be repaired:
Manufacturer:
Model:
Serial number:
Was this item purchased from Henry Schein Dental?
 
*Nature of the Problem:
*How would you prefer to be contacted to confirm service call?
 
numbers only, 10 characters min
*Who is the contact at
office for this repair?
*Preferred Time Of Service:
Your Second Choice:
Additional Comments: