Interneck Fax or Mail Order Form
(not a shopping cart)
Shipping
Featuring LOW shipping prices!
Fax this portion to 800-507-8333 then call during bidness hours to confirm.
Purchaser Info
: name. Previous Patient?
company (if applicable)
address
city state zip
daytime telephone
email
(Optional) Ship to different address:
(Receipts are mailed to the purchaser address unless you check here to include w/shipment)
name
company
address
city state zip
daytime telephone
Gift Certificate/Gift Note Card Information: (Optional)
Occasion
To
From
Message
Style(s) Desired and Size
Price$35.00 ea.
Charge my Visa Master Card AmEx, or Discover:
card # exp. datesec.code

Signature________________________Your Net Total $
Georgia residents add 7% sales tax (excluding shipping) $
I was begat by: ($5 will be sent to Registered Bukk Fambly Member named here: person/town)
(Who told you about Dr. Bukk?)
Please Indicate Your Choice

First Class Mail $3.
3-10 days, delivery confirmed.

Priority Mail - $6.00 (up to 4 sets) 2 to 6 days, delivery confirmed.

UPS
M-F delivery (up to 4 sets). Include company name, street address & telephone number. Guaranteed and trackable. Signature Required.

Order Total

International Only

Ship Amt$


Gift certificates which are custom laser printed are available. To order gifts for more than one destination, please submit separate forms for each shipping destination. Multiple discounts still apply.


Payment

We accept checks, money orders, credit cards and Paypal

Privacy Policy

Dr. Bukk, Inc. has never and will never sell or rent out our mailing list.

Add-Ons
Gold Teeth
A genuine 10 /14 ct. gold cap can be added to any style except Eleanor Roosevelt, It, Shagadelic, ÜberBukk and YouDahMan. Price $25 ea.
Gold Style Desiredon which teef
Gold Style Desiredon which teef
Braces $30 - 6 brackets plus wire applied, no glue.yes no
Rhinestone $5 - yesno

800-925-2855
706-855-0081

Hours: M-F 10-5:30 EST

©2005: Dr. Bukk, Inc. All Rights Reserved
Dr. Bukk, Inc.
704 S. Old Belair Rd.
Grovetown, GA 30813