325 Park Avenue Saint Paul, MN 55115-1643 651/426-0059

QTY
DESCRIPTION
EACH
TOTAL
  Complete Magic Kit #1
$89.95
 
  Complete Magic Kit #2
$99.95
 
  Dentallusions Live Video  
  With a magic kit purchase
$10.00
 
  Without a magic kit purchase
$15.00
 
SUBTOTAL  
Add $10.00 for shipping and handling in US  
Additional shipping charges when ordering multiple kits or shipping outside US.  
Add sales or use tax when applicable  
TOTAL DUE  
  Please clearly print shipping information below:
Name
___________________________________________________________
Company ___________________________________________________________
Address ___________________________________________________________
City ____________________________ State __________ Zip __________________
Country ___________________________________________________________
Phone# _______________________________________ E-Mail or FAX  _____________________
Yes! I am ready to learn the trick to a healthy smile. I understand that magicians do not reveal their secrets. My signature below indicates that everyone in our dental office takes the magician's oath -- no matter how much our patients beg us to tell the secrets, we will not give in.

FORM OF PAYMENT Check ____ (Drawn on US Banks Only) Credit Card ____ Visa ____MC
CREDIT CARD# ______________________________ Expires _____________
SIGNATURE _________________________________________________


Please print this form and mail to:
325 Park Avenue, Mahtomedi, MN 55115-1643

To Place an Order by Phone or For a Free Color Catalog Call:
1-800-568-3464 or (651) 426-0059


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