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

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(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

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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?)

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 Desired None Plain Rim Job Star Mercedes BMW Mickey Mud Flap Girl Anchor Heart Dollar Sign on which teef Bodnia Bukk Chikklets Cowcatcher Final Four Gnarly Incest Interview Lombardi Make That Spare! The Real McKoy Niblits Old Yeller Smokers Speed Summer Sukkula Tuskany Windsor YouDahMan! Zipper na
Gold Style Desired None Plain Rim Job Star Mercedes BMW Mickey Mud Flap Girl Anchor Heart Dollar Sign on which teef Bodnia Bukk Chikklets Cowcatcher Final Four Gnarly Incest Interview Lombardi Make That Spare! The Real McKoy Niblits Old Yeller Smokers Speed Summer Sukkula Tuskany Windsor YouDahMan! Zipper na
Braces $30 - 6 brackets plus wire applied, no glue.yes no
Rhinestone $5 - yesno