Contact Name
*
Business Name
*
Title
Dr.
Mr.
Mrs.
Ms.
Mailing Address
Phone #
Fax #
Email #1
*
Email #2 (Optional)
Date of purchase?
Invoice #
Intended Usage ?
Please select...
General Dentist
Periodontist
University
Military
Research
Other
System purchased?
Please select...
1st FP32 Full System
2nd FP32 Full System
FP Docking Station
FP32 Software only
My system was purchased from:
Please select...
Florida Probe Corporation
Vendor/Distributor
Name of Vendor/Distributor, if applicable:
How many computers are there in the office?
1
2
3
4
5
6-9
10+
How many computers are in the operatories?
1
2
3
4
5
6-9
10+
Are you using laptops or full sized computers with the Florida Probe?
Laptops
Full sized
What practice management software program do you use?
Comments/Suggestions?
Would you like to receive a free pack of 3 replacement titanium tips
($15 retail value plus freight).
Yes | No
Thank you! This information is for our internal use only. All information is kept confidential. Please sign up on our
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if you would like to keep up to date on the latest advancements, price discounts and news on the Florida Probe System.
Please note that from the date of your full FP32 system purchase, you are eligible for a 1 year parts and labor warranty under "normal use".
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