I authorize Lee& Lee Dental Associates PC, 829 East Schaumburg Road, Schaumburg, IL 60194, USA to keep my signature on file and directly charge my credit card account for purchases of products made by telephone or fax. I also agree to pay associated shipping, handling and insurance charges which will be added when the products are shipped.
Check one:
[ ] Mastercard [ ] Visa [ ] Discover/Novus [ ] American Express
Credit Card Number: ____________________________________________________
Expiration Date: ________________________________________________________
Cardholder Name: ______________________________________________________
Signature: _____________________________________________________________
Billing address of credit card (must match credit card or bankcard records):
Address: _______________________________________________________________
City, State, Zip, Country: ___________________________________________________
Products Being Purchased (*products are 110v-120v based):
Oxygene® Toothpaste, case of 6, @ US$60.00
per case X Qty______ = $__________
Oxygene® 16 oz. Fluoride Rinse, case of 6,
@ US$60.00 per case X Qty______ = $__________
Oxygene® 128 oz. (gallon) Fluoride Rinse
with 1 pump @ US$58.00 X Qty______ = $__________
Oxygene® 4 oz. Dental Gel with Fluoride,
case of 6, @US$66.00 X Qty______ = $__________
*Oxycare 3000™ Hydromagnetic Oral Irrigator @
US$152.00 X Qty______ = $__________
*Rotadent® Professional Plaque Removal Instrument
@ US$136.00 X Qty______ = $__________
All products are shipped fully insured to the United States, Canada or International. Actual shipping and Insurance (S/I) amounts will be added to your product order. You will receive the products in about 1-2 weeks after receipt of your fax order. Handling charges are US$5.00 for orders under US$100.00
OVERALL PRODUCT TOTAL US$_______________ + S/I charges + US$5.00 (if under $100)
Signature: _____________________________________________
Date: _________________________________________________