|
Name:___________________________ |
|
Shipping address:___________________________ |
|
City______________ |
|
State or province:________________ |
|
Zip:_________ Country:________________ |
|
Visa ( ) Mastercard ( ) |
|
Credit card#___________________________ |
|
Expiration Date(mm/yy):____/____ |
|
Name on card:__________________________ |
|
Item |
Quantity |
Price |
|
4 tubes of PureWhite 16% |
____ |
$25.00* |
|
4 tubes of PureWhite 11% |
____ |
$25.00* |
|
New Custom Heat & Form Bleaching Trays, includes 6 syringes of
16% PureWhite, Includes S&H |
____ |
$39.00 |
|
Complete whitening system, includes 12 syringes of 16% PureWhite |
____ |
$99.00 |
|
Shipping:
|
|
|
$10 S&H Fees apply |
|
Next Day [ ] add $10.00 |
|
|
International orders please add $7.95 |
*Gel orders will have $3.20 priority shipping added to the
order.
Ca residents, sales tax applies
|
Total:_____________
No Tax |
|
I agree to using carbamide peroxide treatment for sole purpose
of whitening my teeth (Signature)__________________________ |
Mail this complete form to us:
Dentech Services
1550 Deer Park Road
Angwin, Ca 94508
|