Bracket System Provided

Bracket Inventory Storage Form

Account Number

Doctor’s Name

Office Address

Total EnclosedNumber of 5x5 cases enclosed

Number of 6x6 cases enclosed

Number of 7x7 cases enclosed

Please be sure each bracket systems is individually packaged. Include this form along with your brackets in a box with your DynaFlex® prepaid FedEx slip. Email IDB@dynaflex.com to receive your prepaid slip if you do not already have one.

040813© 2012 DynaFlex® , St. Louis, MO 63074. Printed in U.S.A. All rights reserved.