REP Services Order Form Word 2003

							                                    R.E.P. SERVICES
                              DENTAL INSTRUMENT RETIPPING
                                           6903 WEST RIDGE DRIVE
                                             BRIGHTON, MI 48116
                                                800.870.3112

Dr. Name:
Address:


Phone:

Email:


         QTY                                         DESCRIPTION




     ________   TOTAL NUMBER OF INSTRUMENTS SHIPPED

          1     Sterilize instruments prior to shipping.

          2     Please pack properly and place in sturdy box. Clearly write return address on outside of
                package and enclose Order form.

          3     Substitution of instrument tips other than what handle indicates may be requested on
                Order form.

          4     Instruments should be shipped insured via USPS, UPS or FedEx.