Order Form

Order Form:

Please send me:

Quantity: packages of the Tongue Cleaner Plus Pack @ $9.95 each.

Shipping is $4.00 for one pack, $5.00 for two packs, $6.00 for three to ten packs.

CA residents pay 7.75% sales tax.

Ship to Information:

(We ship UPS - No P.O. Boxes Please! We do not ship outside the USA.)

Ship to Name:

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Ship to City: Ship to State: Ship to ZIP:

Phone Number:

e-mail address:

Payment Information:

Credit Card:

Card Number: Expiration Date:

Bill to Information:

Bill to Name:

Bill to Street Address:

Bill to City: Bill to State: Bill to ZIP:

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Please order our dental instruments through your dental dealer! Tongue Cleaner Plus Pack Includes - 2 TONGUE CLEANERS - 5 "SQUEEZE ITS" Only $9.95

Includes:
		and a FREE surprise bonus gift while supply lasts


4 easy ways to order: 1) By Phone, Please call 800-350-3705 during business hours (Pacific Timezone) 2) By Fax, Please print out this form and fax it to 949-249-2705 (24 hours) 3) By Mail, Please print out this form and mail it to Professional Results, Inc, 17 Phaedra, Laguna Niguel, CA 92677, USA 4) Directly through this website: Please fill out this form and press the ORDER button

Order Form: Please send me: Quantity: packages of the Tongue Cleaner Plus Pack @ $9.95 each. Shipping is $4.00 for one pack, $5.00 for two packs, $6.00 for three to ten packs. CA residents pay 7.75% sales tax. Ship to Information: (We ship UPS - No P.O. Boxes Please! We do not ship outside the USA.) Ship to Name: Ship to Street Address: Ship to City: Ship to State: Ship to ZIP: Phone Number: e-mail address: Payment Information: Credit Card: Card Number: Expiration Date: Bill to Information: Bill to Name: Bill to Street Address: Bill to City: Bill to State: Bill to ZIP: Phone Number:








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