Account Number
Office Address
Doctor’s Name
Bracket Inventory Storage Form Bracket System Provided Number of 5x5 cases enclosed
Total 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.