The VELscope

* 1st VELscope Serial #:

* Date of Purchase Unit #1: Select Date

2nd VELscope Serial #:

Date of Purchase Unit #2: Select Date

3rd VELscope Serial #:

Date of Purchase Unit #3: Select Date

4th VELscope Serial #:

Date of Purchase Unit #4: Select Date

5th VELscope Serial #:

Date of Purchase Unit #5: Select Date

6th VELscope Serial #:

Date of Purchase Unit #6: Select Date

Which dealer did you use to purchase your VELscope system? Select One ---- U.S. ---- Arnold Dental Supply Atlanta Dental Supply Company Benco Dental Supply Burkhart Dental Supply Goetze Dental Johnson & Lund Leventhal & Sons, Inc. Midwest Dental National Medical Dental Technologies Patterson Dental Supply Sullivan Schein U.S. Government Agency U.S. Educational Institution Valley Dental Equipment Company-AZ, Inc. ---- Canada ---- Henry Schein Ash Arcona National Dental Patterson Dental Supply Sinclair Dental Canadian Government Agency Canadian Educational Institution ---- UK and Ireland ---- Optident Limited ---- New Zealand and Australia ---- Inline Systems ---- France ---- Opsyse ---- Germany and Austria ---- Rocker & Narjes GMBH ---- Italy ---- Mectron SpA ---- Czech Republic, Slovakia and Poland ---- B+B Servis ---- Switzerland ---- Kaladent AG ---- Hong Kong ---- HealthCare Dental Ltd. ---- Singapore ---- IDS Dental Division ---------------------------------------------- Other

Name of Dealer Rep:

*First Name:

*Last Name:

Practice Name or Company:

Title/Specialty: Select One General Practitioner Endodontist Prosthodontist Endodontist Orthodontist Periodontist Oral Surgeon Pathologist Denturist Other

*Address Line 1:

Address Line 2:

*City:

State/Province:

*Country: Select One American Samoa Argentina Australia Austria Bahamas Barbados Belgium Bermuda Brazil Canada China Cuba Czech Republic Denmark Finland France Germany Greece Holland Hong Kong India Indonesia Ireland Italy Japan Malaysia Mexico New Zealand Norway Philippines Russia Singapore Slovakia South Africa South Korea Sweden Switzerland Taiwan Turkey United Kingdom USA Yugoslavia Other

Zip/Postal Code:

*Phone No.:

Fax No.:

*E-mail Address:

Website:

How did you learn about VELscope? Colleague/Peer Continuing Education Lecture Dealer Rep/Dealer Oral Cancer Prevention Education Seminar Patient Information Request Peer Referal Study Club TV/Newspaper/Radio Trade Publication/Article Trade Show Website Other

If 'Article', which publication?

If 'Trade Show', which one?

If 'Lecture', name of lecturer?

If 'Other', please specify

Expected number of VELscope examinations per day:

Digital camera used at your practice:

Estimated dental practive annual revenue