The Emergency Department Dental Kit

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Emergency Department Dental and Putty Kit Order Form

Number of Original ED Dental Kits
Adult Kit
Pediatric Kit
$412.00/kit plus shipping/handling
Number of ED Dental Putty Kits
Adult Putty Kit
Pediatric Putty Kit
$412.00/kit plus shipping/handling
Bill To:
Name:*
Your Email*
Address:
City:*
State:*
Zip:*
Shipping Address*
- Same as billing address
- Use different address
Ship To:
Shipping Address:
Shipping City:*
Shipping State:*
Shipping Zip:*
Contact Person Name:*
Dept:
Phone#:*
Fax#
Delivery: (Ground) Allow 7-10 business days from confirmation of order

Method of Payment:
Purchase Order #
Payment Mode*
- Pay By Check
- Pay By Credit Card
Exp. Date*
Credit Card: Visa/MC (circle) #*
Security Code*

Mail Payment / Send all Correspondence to:

Mail Payment / Send all Correspondence to:
Surgical Marketing, Inc.
12264 El Camino Real, #111
San Diego, CA 92130
Fax#: 858-509-0912
Phone #: 858-314-8305
Email:orders@dentrauma.com
Website: www.dentrauma.com

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Home
The Kits
Instructions
Order
Our Customers
Contact Us
About Us

Copyright 2009 Adel Tawfilis, DDS. All Rights Reserved