Quantity	Item	Price per unit	Total
	The BreathRx Starter Kit	$13.99
	FLUORIDEX DAILY DEFENSE ENHANCED WHITENING TOOTHPASTE	$10.00
	FLUORIDEX PRESCRIPTION FLUORIDE WITH KN03	$10.00
	FLUORIDEX DAILY DEFENSE PASTE	$9.00
	FLUORIDEX DAILY RENEWAL RINSE	$12.00
	FLUORIDEX DAILY RENEWAL PASTE	$9.00
	CloSYS II Combo Package - Oral Spray, Toothpaste, Rinse	$25.00
	NiteWhite Mini Kit**	$45.00
	** Please print and return this form prior to shipment
		final total*
Purchasing multiple items will qualify for a shipping discount! Please email for details. *Actual UPS Ground shipping cost will be added to your final total.

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To complete your order by fax or mail, please provide the following credit card information:

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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