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
Discover
Prices effective January 1, 2005. All prices subject to change without notice.
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