marquis
Toll-free: (800) 359-3206
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individuals

INDIVIDUAL ORDER FORM

 

Product Name

Perio-Aid #2 (double ended)

Perio-Aid #3 (single ended)

Toothpicks - Diamond Brand Square Center Round Tip 250 CT/BOX

Interdental Brushes - Straight

Interdental Brushes - Tapered

 

Shipping and Handling Pricing:

 
 
Perio-Aids
1 -6 : $4.50, 7 or More: $6.75
Toothpicks
* If toothpicks are ordered with Perio-Aid
1 Package: $4.50
2 Packages: $7.50
Add an Additional $2.00 per Package to Perio-Aid Shipping Charge
Interdental Brushes
* If Interdental Brushes are ordered with Perio-Aid or Toothpicks
$ 3.00
FREE SHIPPING on Brushes

*Please note: Tax is not included

 

Billing Information:

 

Name on Card:
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Expiration Date:
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Billing State:
Billing Zip:

 

Shipping Information:

Same as billing

 

First Name:
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