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3 | UltraSharpLLC@gmail.com | (813) 586-3147 | www.UltraSharpDental.com | |||||||||
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5 | Practice Name | Visa/ MC/ AMEX/ Discover Card Number (Heartland Dental offices please leave blank) | Exp. Date | |||||||||
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7 | Shipping Address (No P.O. Boxes) | Name on Card | CVV Code | |||||||||
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9 | City, State, ZIP/Postal Code | Billing Address | Same as Shipping | |||||||||
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11 | **Contact Name & BEST MOBILE PHONE NUMBER to call for direct contact (NOT office phone number)** | **BEST EMAIL ADDRESS for direct contact (NOT office email address)** | ||||||||||
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13 | Qty | Name of Instrument (Written on the handle of instrument) | PLEASE SELECT HOW YOU WILL BE SATISFYING YOUR OUTSTANDING PAYMENT | |||||||||
14 | Credit card information entered above | |||||||||||
15 | Pay at the time of delivery | |||||||||||
16 | Pay online | |||||||||||
17 | Other (Heartland Dental offices select here) | |||||||||||
18 | PLEASE SELECT YOUR DELIVERY METHOD | |||||||||||
19 | Same-Day Delivery ($2.50/end+Shipping/delivery fee) | |||||||||||
20 | Standard Delivery ($2.00/end + Shipping/delivery fee) | |||||||||||
21 | Student Special ($1.75/end) | |||||||||||
22 | Other | |||||||||||
23 | Office Use Only | Discount Code to Apply: | Prepaid Label $10 | Return Shipping $15 | Pickup & Delivery | |||||||
24 | Date Recieved & Total Counted | _______________________________ | ||||||||||
25 | X________________________________________________________________________________________________ | |||||||||||
26 | Date Sent & Total Sharpened | |||||||||||
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28 | Invoice #: | Signature | Date | |||||||||
29 | Discount applied: | **I authorize UltraSharp, LLC to provide services and/or charge the credit card listed above for the agreed amount upon purchases.** | ||||||||||
30 | Total to be charged: | |||||||||||
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32 | SERVICE AGREEMENT | |||||||||||
33 | *We sharpen carefully and professionally by hand only. We test each instrument for sharpness with an acrylic test stick. | |||||||||||
34 | *All instruments must be sterilized BEFORE being shipped/picked up for sharpening and AFTER they are returned to your office. Unsterilized instruments sent to UltraSharp, LLC will be returned to the customer (shipping charges will apply). | |||||||||||
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36 | *Please package your order in a sturdy box and securely tape it close to be picked-up or shipped (no envelopes please). UltraSharp, LLC is not held responsible for any lost or damaged items during trasnsit. | |||||||||||
37 | *Prior to sharpening, count all instruments accurately and group similar instruments together. Label each sterilization package. (No casettes please) | |||||||||||
38 | *For same day mobile service it will take approximately 2-3 hours depending on how many instruments you need sharpened. | |||||||||||
39 | *We recommend having your instruments professionally sharpened every 2-3 months. Every office will vary and you can set your own schedule. | |||||||||||
40 | *We do NOT offer re-tipping. | |||||||||||
41 | *We sharpen all brands of hygiene instruments | |||||||||||
42 | *Sharpened, altered, custom, irregular, or abused instruments are NOT a guarantee. | |||||||||||
43 | *It is the offices responsibility to sterilize the instruments following the sharpening services according to Public Health and OSHSA standards. | |||||||||||
44 | *Prices are determined by the number of ends per instrument plus tax. | |||||||||||
45 | *UltraSharp is not responsible for previous damage to instruments, including but not limited to the following: over sharpening, incorrect sharpening, or over use of the instrument. UltraSharp will not sharpen instruments that have been re-tipped, have previous damage, or present patient safety concerns, instruments will be returned at no cost to the client. | |||||||||||
46 | *A Service Agreement form must be filled out prior to the sharpening service | |||||||||||
47 | Updated September 10, 2022 | |||||||||||
48 | THANK YOU FOR CHOOSING ULTRASHARP! | |||||||||||
49 | X______________________________________________________________________________________________ | |||||||||||
50 | Signature | Date | ||||||||||
51 | By signing this form, I agree to the terms and conditions outlined above by UltraSharp, LLC | |||||||||||
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