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Date _________________________________

Check Here If First Order_________________

Ordered By ____________________________

Name __________________________________________________ Phone (_______)_________________________

Fax Number: _____________________________________________

Address_________________________________________________________________________________________

City __________________________________________________________ State ___________ Zip ______________

Salesperson _____________________________________________________________________________________

Order, Pricing and Product Questions:

Toll Free:

800-626-2163

Fax Order Line: 920-866-1865

Toll Free Fax: 1-888-681-5088

Account #:

______________________________________

Sub Total:

Shipping:

Fuel Surcharge:

{This fuel charge will be monitored an

adjusted on a regular basis.)

Handling Fee:

TOTAL:

Qty

Item#

Size/Color

Product Name/Description

Unit Price Extended Price

Bill My Account

(With Approval-See Terms)

(Inside front cover)

Check-by-Phone

Payment Method Choose One:

$0.00

TBD

Check-by-Phone Has Replaced C.O.D.'s

Our customers are enthusiastic about our Check-by-Phone service. Check-

by-Phone is faster than C.O.D. and saves you the $10.00 or $10.50 fee. To

use Check-by-Phone just tell your Account Manager or Customer Service

Representative your check information. It’s that easy! No C.O.D., no extra

charge; it’s all taken care of!

Local Delivery:__________________________

*The above amounts are subject to change.

Credit Card

Please call the Dental Health Products, Inc.

Billing Department with your credit card information.

(800-626-2163)

Order Form