PATIENT ORDER FORM
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fill it out and mail with your check. Name____________________________________________________ Address__________________________________________________ City______________________________ State_____ Zip__________ E-mail____________________________________________________ Name of your dentist_______________________________________ Dentist's address___________________________________________ Dentist's Zip__________ Package: #1_______ #2________ #3_______ #4_______ #5_______ #5_______ Prices Shown are in US Dollars DentaPX are avilable to US residents only. Please make checks payable to "Denta Distributing Inc." Mail to: Denta Distributing Inc. 7 Cherokee Bay Winnipeg, MB Canada R2J 2C4 |