Dental Waterline Cleaner Filter Registration Campaign Form Dental Waterline FilterRegister your new Hu-Friedy Waterline Filter for more information about the product and to receive an automatic reminder when it is time to order a replacement. Practice Name Contact Name Dr. First Name Dr. Last Name Office Address Office Address 2 Country - Select - United States Canada City State - Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Province - Select - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon ZIP Code Office Email Address If part of a group practice, specify group practice name Dealer/Distributor - Select - Benco Dental Supply Darby Dental Supply Henry Schein, Inc. Patterson Dental Company Other Other Purchase Date on Invoice Invoice Number Quantity - Select - 1 2 3 4 5 6 7 8 9 10+ Lot Code Upload a Copy of Invoice Upload One file only.2 GB limit.Allowed types: txt pdf doc docx xls xlsx. Submit Leave this field blank
