Cosmetic Teeth Order Form
You can fill out and print this page for faxing (credit card orders only) or mailing your order to us. No information will be transmitted to us by filling out this form. This is not an automatic shop cart! If you want to use a secure internet shop cart or need additional help on ordering, click here.
Billing Information Ship Elsewhere? Yes No
name
name
billing address
billing address
address 2
address 2
citystate zip
citystate zip
daytime phone
daytime phone
cc#
exp.security code		 NOTE: If you use this option, we will obtain verification from the cardholder before shipping.
Note: red color indicates a field is optional. Addresses are verified on all charge customers.
Cosmetic Teef Wanted
Quantity Description
Price
Your Cost
Imako v.3
$49.95 ea.
Ship Options First Class Mail
$3.00
Priority Mail (2-4 days)
$6.00
UPS Ground (1-6 business days)
$10.50
UPS 3 Day Select (end of 3rd bus. day)
$12.50
UPS 2nd Day Air (end of 2nd bus. day)
$17.50
UPS Next Day Air Saver (end of next bus. day)
$24.50
UPS Next Day (10:30 am next bus. day)
$27.50
International USPS Global Priority Mail
$15.00
*UPS cannot ship to P.O. Boxes. Signature Required. Total
Fax this sheet to: 800-507-8333

Voice Telephone: 800-925-2855

Hours: M-F, 10-5:30 EST

Mail this Order Form with payment to:

Dr. Bukk, Inc.
704 S. Old Belair Rd.
Grovetown, GA 30813

All major credit cards, personal checks and money orders accepted, orders shipped w/in 24 hrs. on weekdays. Personal checks will delay shipping until cleared.

Disclaimer: This product is not a medical device nor intended for medical or dental use. This product is not intended for use in lieu of one's own natural teeth. This product is not for use in the diagnosis of disease or other conditions, or in the cure, treatment, mitigation, or prevention of disease in man or other animals. Not for use with braces dentures or other oral appliances.