A)
Name of Dental Office Impression was Taken at:__________________________________
Address:________________________________________________________________
City/State:_______________________________________________________________
Telephone:(___)___________________________________________________________
Patient's Name:____________________________________________________________
Date Shipped By Doctor:_____________________________________________________
Date Needed by:___________________________________________________________
B)
Athletic Purchaser:________________________________________________________
Address:________________________________________________________________
City/State:_______________________________________________________________
Telephone:(___)___________________________________________________________
For Rubber circle one of the following:
|
For Thermoplastic Vinyl circle one of the following:
|
|
Circle type of Mouthpiece:
|
______________________________________________________________
______________________________________________________________
______________________________________________________________
*Please mail check along with the order, make checks payable to:
Rudy Tellez*
|
TOTAL:______________________
SHIPPING and HANDLING $ 9.95
TOTAL DUE:___________________ |
Amateur & juvenile boxers: $79.95
Adults: $99.95 Three-color mouthpiece: $224.95 Professionals: $179.95 |