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(Please Print From Your Printer And Mail To Us)

STERILIZATION MONITORING SERVICE APPLICATION FORM

Name:

Address:

Phone:

CONTACT:

Please indicate how many of each type of sterilizer your office has:

Unsaturated Chemical Vapor  (e.g. Harvey Chemiclave)

Steam Autoclave

Dry Heat

Ethylene Oxide

Please indicate whether you wish weekly or monthly monitoring:

For each unit $120 (monthly) per year

For each unit $375 (weekly) for 48 weeks

How many sterilizers total?

PO#

Return this completed application form with your check to:

STERILIZATION MONITORING SERVICE
University of Oklahoma College of Dentistry
Attn: Ms. Charlene Shaw
Oral Diagnosis
P.O. Box 26901
Oklahoma City, OK 73126-0901