Order Form

To order multiple items to be shipped together, for orders shipped outside of the U.S., or to fax your credit card information or mail your payment to us.

Quantity Item Price per unit

Total
The BreathRx Starter Kit $15.99
FLUORIDEX DAILY DEFENSE ENHANCED WHITENING TOOTHPASTE $11.50
FLUORIDEX PRESCRIPTION FLUORIDE WITH KN03 $11.50
FLUORIDEX DAILY DEFENSE PASTE $11.50
FLUORIDEX DAILY RENEWAL RINSE $13.50
PerioRX Chlorohexidine Rinse $13.00
CloSYS Package – Toothpaste, Rinse $25.00
NiteWhite Mini Kit** $49.00
Final total*

Purchasing multiple items will qualify for a shipping discount! Please email for details. *Actual UPS or USPS Ground shipping cost will be added to your final total.

Name: (Required)
Company:
Street Address: (Required)
City: (Required)
State: (Required)
Country: (Required)
Zip: (Required)
Telephone: (Required)
Fax:
E-Mail: (Required)
Comments, Requests, Questions:

 

To complete your order by fax or email, please provide the following credit card information:

Card Name:
Mail or fax this form to:Robert A. Milner, D.D.S.
27725 Santa Margarita Parkway, Suite 120
Mission Viejo, CA 92691Phone (949) 859-8899
Fax (949) 859-5042
Email dr.milner@ppdg.occoxmail.com
Card Type: Master Card
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Credit Card Number:
Exp.Date:

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Robert A. Milner, D.D.S.
27725 Santa Margarita Pkwy #120
Mission Viejo, CA 92691 (949) 859-8899