Chromiq™ Demo Kit Order Form

Please submit one form per account number/office location.

Each kit contains four lenses, one of each Chromiq™ color in a logoed case, and a UV box for demonstration.

If your office requires additional demo kits, please contact your GSRx Territory Representative.

GSRx Account Number

Office Name

Please submit one form per account number/office location.

Each kit contains four lenses, one of each Chromiq™ color in a logoed case, and a UV box for demonstration.

If your office requires additional demo kits, please contact your GSRx Territory Representative.

GSRx Account Number

Office Name

Chromiq™ Demo Kit Order Form