How to Order


Just fill in all your order details by using the Pull Down Tabs, enter your personal details and click the SUBMIT
button at the bottom of the page. You will receive a Thank You For Filling Out This Form screen. This means
the order has been sent successfully! The order is then manually processed and you'll receive confirmation of the
order within 24 hours.


*This order form uses Thawte (Tm) certificate to ensure secure transmission of online transactions.



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Prostheses

Item#

Shade

Price

 

Medical adhesive and solvent

 

 

Quantity

 

 

Accessories

 

 

Quantity

 
     
   
   

Sub Total: 

   
   

Total: 



Name:
(as it appears on card)
Address:
City:
State/Prov:
Country:
Zip/Post Code:
Phone:
Email:
Date of birth:

Method of Payment
Mastercard Visa Cashier's Check (no personal checks)
Bank Card Diner's Club
Electronic Transfer (email me for details)

Credit Card Number:
Expiry Date: