We must be willing to let go of the life we have planned, so as to have the life that is waiting for
Idea Transcript
210-276-0042 Today’s Date ________ Date Requested __________ Doctors Name _________________ Practice Location _____________ Patients Name ___________________ M/F Age ______ Shade ______
Non Precious Noble Semi P. H. Noble White H. Noble Yellow Titanium
Non Precious Noble Semi-Precious White Noble Semi-Precious Yellow (Y+) Full Gold
Removables Partial
Dentures
Val Plast
Repair
____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Terms: Net 30 days - Past due balances shall carry interest at the maximum legal rate. Orders not paid within 45 days of statement will be placed on C.O.D. The Dentist will be responsible for the collection costs including attorney’s fees incurred in the event that account collection becomes necessary.
Dr. Signature _______________________________ License No.# _______________________