Common Sense Dental domestic online order form only.
If you are NOT in the U.S. please contact one of our distributors.
*Please DO NOT enter free items in quantity field*
Free items should only be listed with the source code below.
Prices effective April 1, 2006. All prices subject to change without notice.
Qty. Description U.S. Price
NuBend120°™ Jar - 1 Jar of 20 pre-filled ampule tips$77.00 Jar
A2 (jar of 20) Logi Bloc $77.00
per jar
A3 (jar of 20)
A3.5 (jar of 20)
B2 (jar of 20)
Logi Bloc
X-Small (yellow) Logi Bloc $21.00 each
Pedo (purple)
Standard (green)
Large (Blue)
PrepCheck - 50 per box, choose from 3 sizes
PC100 1mm (Pink) PrepCheck $89.00 each
PC100 1.5mm (Green)
PC100 2mm (Blue)
Flexi Wedge
Flexi Wedge™ Complete Kit

Kit includes 100 blue, 100 orange, 100 green, 50 purple, and 50 red wedges for a total of 400 wedges per kit.

$88.00
Flexi Wedge™ Refill - 50 ct Red $22.00
Flexi Wedge™ Refill - 50 ct Purple $22.00
Flexi Wedge™ Refill - 100 ct Green $22.00
Flexi Wedge™ Refill - 100 ct Orange $22.00
Flexi Wedge™ Refill - 100 ct Blue $22.00
5" Hemostat (recommended for placing the wedge)
Straight   $10.00

Please enter source Code from print ad, mailer or website:
Free items should only be listed below. Please indicate preferences for any free items you are receiving with this source code - these items should not be included in your order above.
(i.e. if you are receiving a free bag of Flexi Wedge Refills or Logi Bloc please indicate which color you would like.)
*** If you do not list your free items above, none will be sent. ***

Ship To:
Dr.'s First Name* Dr.'s Last Name*
Address*
City* State* Zip* (postal code)
Country*
U.S.       Other
Phone* Fax
Email
Ordering Contact
How did you hear about us?
optional


For Delivery in Michigan, a 6% sales tax will be added.
For Delivery in Texas, a 6.25% sales tax will be added.
Method of Payment:
C.O.D. - U.S. Only ($9.00 will be added to shipping charge)
Credit Card (please fill out all information below)
Card Holders Name
Credit Card Number EXP Date Card Type
Visa
MasterCard
American Express
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Prices effective January 1, 2005. All prices subject to change without notice.
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