Quantity	Item	Price per unit	Total
	The BreathRx Starter Kit	$15.99
	FLUORIDEX DAILY DEFENSE ENHANCED WHITENING TOOTHPASTE	$10.00
	FLUORIDEX PRESCRIPTION FLUORIDE WITH KN03	$10.00
	FLUORIDEX DAILY DEFENSE PASTE	$10.00
	FLUORIDEX DAILY RENEWAL RINSE	$12.50
	FLUORIDEX DAILY RENEWAL PASTE	$10.00
	CloSYS II Combo Package - Oral Spray, Toothpaste, Rinse	$25.00
	NiteWhite Mini Kit**	$45.00
	** Please print this and fax to 949-859-5042 if ordering NiteWhite Kit
		final total*
Purchasing products totaling $100.00 (Before Shipping Charges) will qualify for Flat Rate Shipping charge of $10.50! Order over $135.00 in products and qualify for "FREE SHIPPING"! Please email for details. U.S. orders only. Shipping cost will be added to your final total. Shipping charges listed on products page.

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Card Name:			Mail or fax this form to: Portola Plaza Dental Group 27654 Santa Margarita Parkway Mission Viejo, CA 92691 Phone (949) 859-8899 Fax (949) 859-5042 Email dr.milner@ppdg.occoxmail.com
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