Schedule My Dental Scrap Pick-Up

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Simply Answer questions below and CLICK the SUBMIT button just below # 7

1. Who Do You Want Us To Pay - ? *

MANDATORY: Please Provide The Name Of The Party We Will Be Paying For The Dental Scrap

1a. First Name *

1b. Last Name

2a. Street Address

OPTIONAL: Where Do You Want Your Payment Sent? (Leave this blank if you want us to call you for these details)

2b. City

OPTIONAL: Where Do You Want Your Payment Sent? (Leave this blank if you want us to call you for these details)

2c. State/Province

OPTIONAL: Where Do You Want Your Payment Sent? (Leave this blank if you want us to call you for these details)

2d. Zip Code

OPTIONAL: Where Do You Want Your Payment Sent? (Leave this blank if you want us to call you for these details)

3. Where Should We Email Your Prepaid Label?

OPTIONAL: Include your Email address where we can send your prepaid label

4. What Phone Number Can We Text Your Tracking Number? *

MANDATORY: We need a phone number in order to confirm the pick-up details

5. What Day & Time Do You Want The Pick-Up Scheduled?

OPTIONAL: (Leave this blank if you want us to call you for these details) MM/DD/YYYY - HH:MM - AM/PM

6. How Would You Prefer To Be Paid?

OPTIONAL: (Leave this blank if you want us to call you for these details)

Pay Pal Or Check

Donate the proceeds to a charity of your choice

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7. Do You Have Questions Or Comments?

OPTIONAL: Please provide any special instructions you need us to follow

Submit

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