3 Appointment Denture CD Order Form

REQUEST FOR INFORMATION:

*Doctor:
*E-mail:
Attention:
*Address:
*City:
*State:		*Zip:
*Phone:		Fax:

1. How many dentures do you do per month?

2. Does your practice use custom trays?

3. Are you having trouble with denture delivery and consistency at this time?

4. Would you be more likely to choose an economy or premium denture?

5. Do you prescribe teeth by a tooth manufacturer or allow lab substitution?

6. Do you select your own moulds?

Denture Preferences:

PRIVACY PROMISE: The Keller Laboratories Inc. website is provided as a resource to our customers and dental professionals. Your information will be used exclusively by Keller Labs. We will not sell or give your address to any third party.