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Click here if you are requesting samples for a Dental College
Request for Samples
Only for Registered Medical Practitioners
(Dentists, Oral & Maxillofacial Surgeons)
Please enable JavaScript in your browser to complete this form.
Email
*
Full Name
*
Phone No.
*
Gender
*
Male
Female
Degrees
Medical Council Reg. No.
*
Specialization
*
Periodontist
Periodontist
Prosthodontist
Oral & Maxillofacial Surgery
Orthodontist
Endodontist
Pedodontist
Other
Clinic / Hospital / Firm Name (optional)
Address Line 1
*
Address line 2
Town / City name
*
Zip code / Pin code
*
Suture sizes that you use most often (select any two)
3-0
4-0
5-0
6-0
Suture materials that you use most often (select upto three max)
Silk
Polypropylene
Nylon (Polyamide)
Absorbable Polyglactin-910 (Violet)
Absorbable Polyglactin-910 Fast Absorbing (undyed)
Monofilament Absorbable Poliglecaprone-25 (undyed)
On an average, how many sutures do you use per month.
*
1-5 nos
6-10 nos
11-15 nos
16-20 nos
20-30 nos
above 30 nos
Select your choice of free samples (any two)
*
select any 2
Silk 3-0, with Medium (20-22mm) needle
Silk 3-0, with Long (24-26mm) needle
Absorbable Polyglactin-910 (3-0) with Medium (20-22mm) needle
Fast Absorbable Polyglactin-910 (3-0) with Medium (20-22mm) needle
Fast Absorbable Polyglactin-910 (3-0) with Long (24-26mm) needle
Polyamide(Nylon) 3-0 with Long 26mm needle
Polyamide(Nylon) 4-0 with small 10mm Rev. Cutting needle
Polyamide(Nylon) 5-0 with 16mm cutting needle
Polypropylene 5-0 with 13mm needle
Polypropylene 4-0 with 15-17mm needle
How did you know about us?
I was referred to you by a colleague
I was referred to you by a colleague
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Company Sales Representative
Mention the referral code/name/phone (any one) of the colleague who referred you to us.
Refer us to your 5 of your colleagues and upon successful registrations by them, you get 1 full box (12 sutures) of Silk sutures (Size 3-0 or 4-0) Worth MRP Rs. 1620.00 FREE of cost.
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