Order Form for Basic Dental Kit

Order Form ...................

Dentist In A Box^™

		Print this page, complete and sign then fax completed form to:
			Within Australia:	(03) 9532 4522
			Outside Australia:	+ 61 3 9532 4522

	Delivery Time	Cost per kit	Number of kits	Cost $AUD
Within Australia	7 - 10 days (approx.)	$ 23.00 AUD	x	$
Outside Australia	7 - 14 days (approx.)	$ 26.50 AUD	x	$

	Send the kits to:
	Name:...................................	..............................................................................................................................
	Address: ..............................	............................................................................................................................
	...............................................	...........................................................................................................................
	Phone No: ...........................	..............................................................................................................................
	Country ................................	.............................................................................................................................

Cards	Accepted	Card Number	Amount
	Mastercard	..................................................................	$A
	Visa	..................................................................	$A
	Amex	..................................................................	$A

	Cardholder Name: .....	.....................................................................................................
	Card Expiry Date:	..................... / ................................
	Cardholder Signature:	.....................................................................................................

Print this page, complete, sign then fax completed form to:

email: dentabox@dentistinabox.com.au

Call us within Australia:	(03) 9528 5388	Call us *outside* Australia:	+ 61 3 9528 5388
Fax us *within* Australia:	(03) 9532 4522	Fax us *outside* Australia:	+ 61 3 9532 4522
Our Postal Address:	84 Glen Eira Road, Elsternwick 3185, Victoria, Australia