*SAME DAY Full Denture and Partial Denture Repair, Order No :88-726241
Call : 1-888-329-6304, 7 Days a Week!
 
Dentists Repair Dentures in a Certified Dental Laboratory!
We Ship Safely w/ $50 Ship. Insurance and Tracking
No Repairs on : Flippers or Flexibles.
Pricing on this form expires : 09/22/10
Lost or Cracked Teeth Replaced with Acrylic Denture Teeth
30 Day Warranty on Repairs,38.107.191.94
Providing Excellence in Customer Care Everyday!
*Repair Time: Same Day up to 3 Bus. Days
Customer Billing and Shipping Information
If credit card used, address below must match card.
Name :  
Address 1 :     
Address 2 :     
City :                          State :        Zip Code:
Phone 1 :     
Phone 2 :     
Email :              
Birthdate :         /        /    
     CALL ME When Denture Arrives. $FREE
    DENTIST INSPECTION of Broken Denture$FREE
     Clean Denture One Professionally. $15
     Polish denture to a glossy smile. $7
     Remove Old Glue from Denture. (Required)$17
    *** Emergency Denture *See bottom notes*$159
  
Note: Need help, just call us, we're here ready to help! Please check Remove Old Glue if you used glue.
     REPAIR You Supply One Loose Tooth$39
     REPAIR Dentist Supply One New Tooth$59
     REPAIR One Crack (Denture Intact) $49
     REPAIR One Break $63
         CALL ME with Shipping Tracking No.$FREE
        EXTRA Crush Resistant Packaging$FREE
  *SAFEST - FEDEX OVERNIGHT S/H - (M. - F.)$29
   USPS Overnight - Express S/H , (M. - Sat.)$24
   FEDEX 2 Business Day S/H - Mon. - Fri.$19
   *ECONOMY - USPS Priority S/H
        USPS 2-3 Bus. Day, Mon. - Sat.		$14
     USPS Stamp Mail - No Ship. Ins. or Tracking$2
     $300 Ship. Insurance Coverage$4
Shipping and Handling Total : $
Grand Total : $
Personal Checks take 3 - 5 days to clear, Write Payment to Basiq Dental Solutions.
Payment Method   
Discover
MasterCard
    VISA
 
    Check           Money Order
Card No. :
Billing Zip Code : Exp. Date: / Required
Security Code:
Signature
Tell the dentist your problem!
Use an "X" for a Missing Tooth, Circle the Tooth if Loose, Draw a Line where your break is.
Dentists Repair All Dentures in a Certified Dental Laboratory. - Dentures are first examined by a Dentist BEFORE ANY REPAIR, FREE OF CHARGE.

Warranties: 30-Day Repair Warranty And 60-Day Emergency Dentures, under regular use. Labor and Materials covered. Provide a copy of your receipt.
Emergency Denture :
Also known as a duplicate denture. - strong enough to eat regular food, comfortable, made for purpose as a temporary backup denture. All Duplicate Dentures should not be used as Permanent Replacement Dentures.