Landis Refining Co, Inc. - Order Container Form

Container Order Form

Please choose the option that best describes you:

Dentist

Dental Staff

Dentist Name:

Dentist Phone:

Patient

Thank you for choosing Landis Refining! To process your request please provide the name and phone number of the Dentist that recommended us to you

Referring Dentist:
Dentist Phone:

Jeweler

* indicates fields the require entry.

Your Name:	*
Business Name:	*
Address:	*
City:	*
State:	*
Zip Code:	*
Contact Name:	*
Email:	*
Phone Number:	*

Ship-to Address (if different):
Name:
Business Name:
Address:
City:
State:
Zip Code:

Single jar box: 5x4x4 in. (please indicate quantity)

Multiple jar box: 7x4x5 in. (please indicate quantity)

Contents Description:
Collecting jars are a standard size: 3 in. tall by 2 3/4 in. diameter.
Boxes are reusable. We enclose a prepaid business reply return label.
The multiple jar box holds three jars comfortably.

Patient Scrap Mailer Package (please indicate quantity)

Contents Description:
Introductory letter.
Eight prepaid self-sealing bubble-lined mailers.
All mailers are a standard size: 7 1/2 in. wide by 5 1/4 in. high.

Message: