REGISTRATION

Register your Valplast appliance to insure
that you’re receiving a genuine Valplast product.

 

Your product is also guaranteed for life. Warranty is
automatically activated through registration.

 

 

    PERSONAL INFORMATION

    First Name*:

    Last Name*:

    Address*:

    Address2:

    City*:

    State/Province:

    Postcode:

    Country:

    Email*:

    PURCHASE INFO

    Dental Practice Name*:

    Dentist's or Dental Prosthetist Name*:

    Dentist's or Dental Prosthetist Phone Number*:

    Date of Insertion*: (mm/dd/yyyy)

    Restoration Type*:

    Material Lot Number*:

    Valplast® Laboratory ID Number*:

    Please type in the serial number* found on the back of your "Smile With Confidence" brochure.:

    ABOUT YOU

    (This information is optional)

    Date of Birth: (mm/dd/yyyy)

    Phone Number:

    Gender:
    MaleFemale

    How did you learn about Valplast®?:

    * Indicates mandatory fields