How to Order the Metalift™ System

[ This product is for professional use only! ]

You may print then fax this order form to Metalift, LLC at (888) 841-5384.
Also, feel free to call us at 1-800-928-9289 or 225-928-0799, or mail to the address below.

[__ ] Yes, I would like to order the Metalift™ Crown and Bridge Removal System
from Metalift, LLC

Each complete kit is $525.00
(plus $10.00 for UPS Ground Service. International shipping: Call or E-mail us for exact shipping cost quote.)

Make checks payable to: Metalift, LLC. Payment will be: (check one)
[__] MasterCard XX[__] VisaXX[__] American ExpressXX[__] DiscoverXX[__] Check

Card Number ________________________________________________________

Name on Card _______________________________________________________

Expiration Date ___________________________ Total Enclosed $ ______________

Signature Required on Credit Card Orders __________________________________

Ship to ______________________________________________________________

Address _____________________________________________________________

City, State, Zip _________________________________________________________

Daytime phone number with area code(_____)___________________________

Office Fax Number (______)___________________________________

Order by Mail, Phone or Fax
Call: 1-800-928-9289 or 225-928-0799 Ext. 11
Fax: 1-888-841-5384

Mail To: Metalift, LLC.
7855 Jefferson Highway, Suite C
Baton Rouge, Louisiana 70809

Additional shipping charges may apply for faster service. Call for more details.