REGISTER EMERGENCY KIT FOR
AUTOMATIC RENEWAL SYSTEM

 
Contact Information
 
Office/Doctor Name
  
Contact Name
  
Address 1
  
Address 2
  

Province

  
Postal
  
Phone
  
Fax
  
Dental Dealer
 
 
Email
  
       
EMERGENCY KIT DETAILED INFORMATION
 
BELOW PLEASE LIST EACH INDIVIDUAL EXPIRY DATE FOR EACH ITEM IN YOUR EMERGENCY KIT

e.g. EPINEPHRINE AUGUST 2008
     
EPINEPHRINE
  
ATROPINE SULFATE
 
DIPHENHYDRAMINE
  
SALBUTAMOL
  
 
INSTA GLUCOSE
  
 
PLEASE NOTE THAT BY REGISTERING YOUR EMERGENCY KIT ONLINE, YOU WILL AUTOMATICALLY RECEIVE NEW PRODUCT REFILLS APPROXIMATELY TWO WEEKS BEFORE YOUR CURRENT PRODUCT EXPIRES. AT THAT TTIME YOU WILL BE BILLED BY YOUR PREFERRED DENTAL DEALER. IF SHOULD HAVE ANY QUESTIONS REGARDING THIS PROCESS, PLEASE CALL OUR CUSTOMER SERVICE DEPARTMENT AT 1-800-667-3770 BEFORE SUMBITTING YOUR INFORMATION.
     
 
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