Handpiece Rescue

2511 27th Ave

San Francisco, CA  94116

(415)823-9488

(415)753-8351 Fax

 

Please fill out this form and send in payment to the address above along with any broken handpieces you may already have.   This information is important so that I can start stocking the necessary parts for your office. 

 

Office Name and address: (Please print clearly)

 

                                                                                               

                                                                                               

                                                                                               

Handpiece Make& Model                                                                                            Serial Number

1                                                                                                                                                                                                             

2                                                                                                                                                                                                            

3                                                                                                                                                                                                             

4                                                                                                                                                                                                             

5                                                                                                                                                                                                             

6                                                                                                                                                                                                             

7                                                                                                                                                                                                             

8                                                                                                                                                                                                             

9                                                                                                                                                                                                             

10                                                                                                                                                                                                          

11                                                                                                                                                                                                          

12                                                                                                                                                                                                          

*Please note the $50 a month fee is based on the average office having a dozen handpieces in operation.  If you office has over 12 handpieces.  There is a $5 fee for each additional handpiece per month.   Please use the back if you have additional handpieces. 


   

Print out form