Practice Name (if different than Doctor's name)______________________________________

_____________________________________________________________________________________

Address:_____________________________________________________________________________

City/State/Zip_______________________________________________________________________

Phone:_________________________________ Fax:_________________________________________

Email (optional):____________________________________________________________________

PAYMENT INFORMATION

Card Type (please circle): VISA-----MASTERCARD----AMEX

Card Number__________________________________________________________________________

Expiration date______________________________________________________________________

ORDER INFORMATION

Product Name: SIMPLICITY (TM) Self-Etch Dental Adhesive System $120/kit

Number of kits___________________

Please submit order form via fax to: (847) 310-0624

Or call 1-877-APEX123 ( 1-877-273-9123)