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Order Form

THIS IS A SECURE SITE. ALL INFORMATION SENT WILL BE ENCRYPTED, AND STORED ON A SECURE SERVER FOR YOUR PROTECTION.


*- Required fields.
 
Customer#:
Customer PO#:
*Phone #:
*E-Mail Address:
Dealer:      Dentist:      Lab:      Other:

Bill To:  
*Name:
*Address:
*City:
State:
*Zip:
*Country:

Ship To (If different from billing address):
Name:
Address:
City:
State:
Zip:
Country:

Ship Via:
Item# Qty Description and Shade US $ Amt.
    Merchandise Total:
All taxes, shipping, and hazardous charges (where applicable) will be added to invoices prior to shipping.  Dealer discounts will be applied as earned.  ORDERS UNDER $50 ARE SUBJECT TO A $10.00 HANDLING FEE.     

Payment Information:
*Credit Card:
*Card Number:
*V-Code (3 digit code on back of MC, Visa ad Discover, and 4 digit code on front of AmEx):
*Name on Card:
*Expiration Date:      Year:   
I have read and agree with the terms and conditions of sale   Agree
If you have any questions relating to this form, e-mail us or call toll-free: 1-800-872-8898

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