Obrazac humanitarnog zahtjeva

All humanitarian requests must be submitted using this form. We will review your submission and respond within the next two weeks.

Organization Details
Dental Office Details
You will be contacted via (email, telephone, etc.) once the request has shipped.
Brief Summary of Organization/Mission:
Humanitarian Mission Details
  1. Number of Volunteers *

Terms and Conditions

I consent to allow Ultradent to use the provided information to contact me regarding and to evaluate my request. If this request is approved, as consideration for receipt of Ultradent product(s) donated for humanitarian purposes I certify that:(i) donated products will not be sold or transferred to anyone for any purpose not consistent with the statements made in this request form: (ii) all dental services required in connection with use of donated products shall be provided to the patient(s) free of charge: (iii) donated products will be used in accordance with their labeled instructions and (iv) I agree to hold harmless Ultradent, The Diversity Foundation and affiliates from any and all liability for use of the donated product(s).