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.

Quantity Item Price per unit

Total
Philips DiamondClean Smart Toothbrush 9400 Professional $155.99
FLUORIDEX DAILY DEFENSE ENHANCED WHITENING TOOTHPASTE $12.00
FLUORIDEX PRESCRIPTION FLUORIDE WITH KN03 $12.00
FLUORIDEX DAILY DEFENSE PASTE $12.00
FLUORIDEX DAILY RENEWAL RINSE $13.50
PerioRX Chlorohexidine Rinse $13.00
Venus Whitening syringe kit (3 syringes w/instructions)** $51.00
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. Call office for Shipping Quote (949)859-8899

Name: (Required)
Company:
Street Address: (Required)
City: (Required)
State: (Required)
Country: (Required)
Zip: (Required)
Telephone: (Required)
Fax:
E-Mail: (Required) Invoice will be sent.
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
Visa
Discover
Credit Card Number:
Exp.Date:

Print This Page