Which Converter? (1 per surgery): *
Which tips do you currently use?: *
Surgery Name: *
We use the Surgery Name in order to accurately dispatch the requested sample.
Surgery Telephone Number:*
We use your telephone number in order to contact you with any queries regarding your request.
Name of dentist who will try Pro-Tip: *
We use this name as a point of contact in order to contact you with queries relating to your request and to accurately dispatch the requested sample.
Practice manager: *
Practice manager email: *
We use your email address in order to contact you with any queries regarding your request.
We use the Surgery Address in order to accurately dispatch the requested sample.
Where did you hear about us?: *
Word of mouth
Exhibition – please state which one
Ad in Trade Journal – please state which one
Search Engine – please state which one
Social Media – please specify
Other website – please state which one
Other – please state
Here at Astek Innovations Ltd we take your privacy seriously and will only use your personal information to administer and provide the products and services you have requested from us.
However, from time to time we would like to contact you with details of other Astek products, offers and services we provide. If you consent to us contacting you for this purpose please tick to say how you would like to us to contact you.
Astek Innovations Ltd
Astek House | Atlantic Street | Altrincham | Cheshire | WA14 5DH | United Kingdom
Telephone +44 (0)161 942 3900 | Fax +44 (0)161 942 3901 | Email firstname.lastname@example.org