GOLDEN GATE HANDPIECE REPAIR FORM 4334 West Washington Center Road Fort Wayne, IN 46818 Phone 1-800-354-7772 Fax 1-888-354-7772

First, you need to print this form  Please fill out and mail with the equipment to be repaired This is your return address, please print

Doctor

Address

City/State/Zip

Phone

METHOD OF PAYMENT: (Circle one)
Ship COD	Visa	MasterCard	AmEx	Discover

Credit Card #
Expiration Date

Credit Card Statement Zip Code

Signature

Handpiece	Serial No	Problem

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