DENTIST/CLINIC REGISTRATION

DENTIST NAME: *
CLINIC NAME: *
LOCATION: *
CONTACT PERSON: *
CONTACT CELL #: *
CONTACT EMAIL: *
Name of your SiOS rep: *
Today’s Date *
Name on card: *
Address of card: *
Your signature *
Enter card number *
MM/YY *
CVC/CVV *
card holder name *

(Pre Order VIP Special: $79,999 thru Feb 28,2025)

The SiOS™ package deposit is fully refundable. Expected commencement of delivery/install will be Q3/4 of 2025. Educational training course dates are being set up in specific locations throughout the U.S. Any refund request must be submitted in writing by email *within the specified 90-day period since submission to: Before the end of 2025 or manufacturer install date is confirmed.