ORDER FORM :
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Fax to : +1 (604) 275-4254
Doctor(s):
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___________________________________
| please print
Delivery Address:
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___________________________________
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___________________________________
Date Ordered :
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____________ [please allow 4-6 wks for delivery]
E-mail address :
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___________________________________
Telephone No :
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___________________________________
Product ID#
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Qty
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Unit Price
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Total Price
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TOTAL :
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Glabell Dental Arts do not charge a handling fee.
Shipping fee of up to $15 may be applied.
Our products are non-taxable.
Payment Methods:
1) [ ] Visa
[ ] MasterCard [ ] AMEX
Credit Card # :
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______________________________
Expiry :
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______________________________
Signature :
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______________________________
OR
2) Money Order
| Payable to :
| GLABELL DENTAL ARTS
| Mail to :
| # 5091 Steveston Hwy
|
| Richmond BC V7E2K5
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| CANADA
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