Phone Order Form

Tooth Fairy System Logo

Use this form to be sure that you have all the answers wen you speak to our account representatives. If you have questions, our representatives will be able to assist you.

Call us Toll Free at: 1 (800) 232-3741
or locally at: (408) 596-6877

Questions you will be asked from the REGISTRATION FORM

Contact Information
First Name, Last Name and Middle Initial Street Address
City, State and Zip
Home Telephone
Work Telephone
Fax number

Education Information
Are you a graduate from a Dental Asst. Program?
Name of School
Campus
Year

Reservation Information
Rental Kit for Practical Exam $125
Seminar for Written Exam (2 days) $275
Workshop for Practical Exam (1day) $250
Seminar for Law & Ethics Exam (4 Hour) $150
Coronal Polishing Course (8 Hour) $500

Date I wish to attend the Practical Workshop
Date I wish to attend the Written Seminar
Date I wish to attend the Law & Ethics Seminar
Date I wish to attend the Coronal Polishing Course
Need to rent a kit?

Payment Information
Total amount to charge
Payment Type
Check, Money Order or Credit Card
VISA MASTERCARD DISCOVER
Card number
Expiration Date
Cardholder Information (if other than yourself)

First Name, and Last Name
Street Address
City, State and Zip
Telephone




Top of page

Dental instruments