Teeth on the Go 2.0

Kit Reservation Form

First Name	Last Name	Job Title
Name of School
Street Address
City	State	Zip Code
Phone	Email

Reminders
We recommend that a kit be ordered 2 weeks in advance of the date it is needed. We will ship it to the school via a commercial carrier. Delta Dental of Virginia will pay for the shipping charges to and from the school.

A kit is on loan to a school for a period of 2 weeks and must be shipped back by the appropriate deadline.

How many kits do you need?
What date do you want the kit to arrive at your school?
What date do you plan to begin teaching the program?