"PRINTABLE" Order Form or fill it and save to the location of

EMAIL:[email protected]
order form and attached scan
remake or supply orders
FAX: 540-265-9164
MAIL: using our preprinted 1st Class or UPS label
If you prefer email or cannot reach us by phone, use [email protected].
Please fill out order form entirely.
Failure to do so may cause delays.
We offer a full line of supplies. Call us or visit our website for more information.
Bill to Acct #
Bill to Address:
Ship To Address: (if different from above)
Ship to Client
Lucite
w/ Body Soft Canal
w/ Emplexll Canal
Clear Brown
Beige
lnvisiear
Pink Tint Other
Brushed Velvet
Highly Polished
Silicone
Emplex
Beige
Brown
White
Pink Tint Multi-Color
Emplex II
Beige
Brown
White
Pink Tint Multi-Color
Comfort Sil Pink-tint Brown-tint
EM3000 Clear Medical Material lnvisiearMulti-Color
Emvinyl Clear Brown
E-Compound (Available in all materials except Emvinyl)
Hypo Allergenic (Available in all materials, required in all silicone molds.)
Slick ’em (Antimicrobial) — available only in EM3000
The Antimicrobial SHIELD — available in all materials
Sparkles Color
(Lucite, Emvinyl, EM3000)
Glow in the Dark (Lucite, EM3000)
Shipping: We ship by the same method received unless
otherwise specified. All orders are subject to additional
charges for shipping.
First Class
Overnight
2 Day
nd
Ground
RUSH: Ships same day received, $10.00/ear
Return Impressions
No Vent
.03
.06
.09
Largest Possible
MiniSAV SAV
4VH (for Slim Tube or RIC)
Semi-iros — approx ½ of lower canal tip removed
Extended Warranty, Additional 6 mo. $10.00/ear
Loss & Damage, 1 year, $12.50 per ear
Baby Warranty, Unlimited Remakes for 1 year,
$30.00 per mold
Special Instructions: (If Remake, please give a full explanation)
Rev. 08/2016