Equipment Order Checklist Equipment Order Checklist Please be thorough and provide adequate detail. Email* Please provide your Goetze email address.Account Number or Project Number*If a new account is needed please have the rep complete the following Account Setup Form - https://goetzedental.com/new-account-account-change-form/Account Name* Equipment OrderingSpecial Cost or Promotional ItemsPlease list any and all with specific details.Order Delivery Timeline* When Product Arrives Rush Order Rush Order ExplanationList Additional Parts to Be Ordered by ServiceDeliveryDelivery LocationKC - Goetze HQDes Moines BranchOmaha BranchSpringfield BranchSt. Louis BranchWichita BranchDenver BranchOtherDelivery Location Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please complete if equipment is being delivered directly to the doctor's office or another location.This order is over $4,000 Yes No A Delivery Charge Agreement Was Signed by the Doctor Yes No Please find a copy of the Delivery Charge Agreement here - https://www....Delivery Charge Agreement UploadAccepted file types: pdf, jpg, png, Max. file size: 300 MB.Please upload the signed agreement here or fax to 816.459.7064.InstallationLocation or Operatory Room Number Where Installation Will OccurPlease provide as much detail as possible.Installation Instructions or ConsiderationsIs There Existing Equipment at the Install Site? Yes No Instructions for Any Existing Equipment in the SpaceList All Equipment to DisconnectList All Equipment to RemoveTechnology and ITDoes this Order Contain Technology Items Yes No Technology Items are defined as computer hardware, networking components and cabling.Who Will Be Completing Installation of Technology Items?Branch TechniciansKC TechniciansDoes this Order Contain EDDSON and/or Imaging Software? Yes No Please Specify All Software to Be Installed and Any Instructions