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Date _________________________________
Check Here If First Order
Ordered By ____________________________
Office Name ______________________________________ Phone (_______) _______________________________
Fax Number: ____________________________________________________________________________________
Address_________________________________________________________________________________________
City __________________________________________________________ State ___________ Zip ______________
Salesperson _____________________________________________________________________________________
Order, Pricing and Product Questions:
Toll Free:
800-626-2163
Toll Free Fax: 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
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!
Credit Card
Please call the Dental Health Products, Inc.
Billing Department with your credit card information.
(800-626-2163)
Supply Order Form