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Name:___________________________ |
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Shipping address:___________________________ |
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City______________ |
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State or province:________________ |
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Zip:_________ Country:________________ |
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Visa ( ) Mastercard ( ) |
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Credit card#___________________________ |
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Expiration Date(mm/yy):____/____ |
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Name on card:__________________________ |
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Item |
Quantity |
Price |
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4 tubes of PureWhite 16% |
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$25.00* |
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4 tubes of PureWhite 11% |
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$25.00* |
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New Custom Heat & Form Bleaching Trays, includes 6 syringes of
16% PureWhite |
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$39.00 |
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Complete whitening system, includes 12 syringes of 16% PureWhite |
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$99.00 |
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Shipping:
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Next Day [ ] add $20.00 |
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Regular mail [ ] $10.00 allow 5 working days |
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International orders please add $17.95 |
*Gel orders will have $3.20 priority shipping added to the
order.
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Total:_____________
No Tax |
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I agree to using carbamide peroxide treatment for sole purpose
of whitening my teeth (Signature)__________________________ |
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Fax this complete form to us. (707)965-0228 |