Amber Mill Trial

Amber Mill Trial

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PERSONAL INFORMATION		LOCATION INFORMATION		CAD/CAM DETAILS		TRIAL PACK OPTIONS

Complete the following information to participate in the Amber Mill Trial Program. HASS BIO America will ship you trial samples at the address that you list in this form. In exchange, we will ask for your feedback. If you have trouble or questions completing this form, please contact us at support@hassbioamerica.com

NOTE: This program is limited to US-based practices/laboratories only.
Name
N/A

Required First Name Required Last Name
Credentials (check all that apply)
N/A
Personal email *
N/A
Mobile Phone
N/A

### ### ####

Organization Name
N/A
Address
N/A

Required Street Address Address Line 2 City State Required ZIP Code

Country
Phone
N/A

### ### ####
Furnace Make and Model
N/A
Work Email
N/A

Milling Machine Make and Model
N/A
Are you currently using lithium disilicate blocks?
N/A
If Yes, name of Lithium Disilicate Blocks you currently use.
N/A

Please select one of the products listed below. In the event you choose both, we will only send Amber Mill.

NOTE: Amber Mill Direct is a pre-crystallized block that does not require oven time.
Trial Packs *
N/A

Select the product(s) you with to try out.
Comments
N/A

1/4

2/4

3/4

4/4

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