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Supply Request Form

Submit the electronic supply order form below to receive free prescription forms, shipping supplies, or literature by mail, or call us at:

Phone: 800-828-7626 (U.S. & Canada) or 716-871-1161 (worldwide)
Hours: Monday - Thursday from 8:00a.m. to 6:30p.m. (Eastern Standard Time)
Friday from 8:00a.m. to 5:00p.m. (Eastern Standard Time)

Supply requests are normally processed within 24 hours.

Please send me:

Appliance Prescription Forms          Download Rx Forms online
(Check all that apply)
Aligner Appliance Rx Herbst®* Appliance and Acrylic Rx
Athletic Mouthguard/Bleaching Tray Rx Metal Appliance Rx
Diagnostic Study Model Rx Perio Protect™ Tray Rx
Elastodontic/Positioner Rx Removable Appliance Rx
Functional/Active Plate Rx Snoring/Sleep Apnea Rx
    Splint Rx
Laboratory Shipping Supplies
Boxes Labels
Catalog(s) (Includes Price List)
Laboratory Catalog

(Choose one of the following Products catalogs)
Orthodontics Prosthodontics    
Monthly Specials Flyer
Yes No
Product Literature
AbsoAnchor Micro Implants Magicryl 2 Acrylic Resin
ACU-flow™ Bite & Impression Registration Material Microimplants in Orthodontics Book
Acrylic Applicator Kit MINISTAR S®
AcuLight® Nola Dri Angle®
Appliance Fabrication DVDs Nola Dry Field System
Biostar® Oral Safe Brochure
BiteStrip™ Philips HeartStart OnSite Defibrillator
Dimo Grinding & Finishing Wheels SAM® III Articulator
Dr. Frank Spear DVD Series SAM® Single Toggle Lock
EZ Key (Expansion Screw Key) Study Model Trimmer Jig
Guide to Orthodontic Appliances Book SleepStrip®
Infection Prevention Products Training Courses Brochure
Keles Face Mask Variflex™ Heat Softening Acrylic
Appliance Literature
Appliance Decal Chart Invisible Inman Aligner
Artist Series Appliance Designs Sleep Appliances
DeLuke Contoured Expander (DCE) Splints/Deprogrammers
DeLuke Oral Trainer (DOT) Tremont
Inman Aligner Xbow™ Appliance
Inman Power Component Appliances    

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Additional Comments:
I would like to receive periodic e-mails about promotions, monthly specials, new products and appliances, as well as upcoming events.
   

* Herbst is a registered trademark of Dentaurum, Inc.