To process your Air Repair Pick-Up Request, please fill out the following three sections and click on SUBMIT. If you have any questions or problems with this form please email Phil Tackett, Customer Service Manager, at ptackett@dentsply.com, or call 1-800-800-7202 and speak with one of our many experience service representatives.

All fields with an *(asterisk) are required.

Section One

Please provide customer information:

Name*
Dealer
Company
Street Address*
Address(cont.)
City*
State/Province*
Zip/Postal Code*
Country
Work Phone*
Fax
E-mail*
Office Hours From:*
Office Hours To:*
Are you open for lunch? (Y/N)*
If not open, close time:

Section Two

Please provide product information:

Product	Serial Number	Qty
High Speeds
Low Speeds
CCS or eStylus
Total # of packages*

Section Three

Please provide the following delivery information and follow the instructions:

Place your Midwest handpiece in our special Air Repair Box. If you do not have an Air Repair box, give us a call at 1-800-800-7202 and we'll be delighted to send you one. Provide the information requested below. A tracking number is printed on the FedEx label. Please be advised that the package needs to be boxed and ready within 30 minutes of the pick-up time.

Tracking Number
Pick-Up Date*
Boxed/Ready Time
Special Instructions

If problems:

Contact Name*
Contact Phone*

DENTSPLY Professional Division
West
901 West Oakton St.
Des Plaines, IL 60018
800.800.2888 Phone • 847.640.6165 Fax

DENTSPLY Professional Division
East
1301 Smile Way
York, PA 17404-1785
800.989.8825 Phone • 717.767.8250 Fax