Local Pick-Up Request

Doctor's Name*

Please indicate the name of the prescribing dentist who is sending the case.

Your Full Name*

Please enter your name so that we may contact you in the event of any questions.

Street Address*

Suite/Building No.

City*

Zip Code*

Email Address*

Phone Number*

Pick-Up Date*

Enter the date when you would like the case to be picked up. AM Pickups must be requested before 5:00pm on the prior day. PM Pickups must be requested before 12:30pm.

Shipping Route*

Enter the route when you would like the case to be picked up. AM is between 8AM-12PM and PM is between 1PM-5PM.

Special Instructions:

Enter any general comments or notes about the pickup. Please note that we are not able to schedule a specific time for pickup.

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