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TheBestTopicalEver.com

PAIN-FREE Dentistry Is Finally Possible!

*** By Dentist For Dentist ***

Tel: 1-888-986-7422

Fax: 1-888-632-9867

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The Best Dentists are using TheBestTopicalEver!

Because your patients deserve TheBestTopicalEver!

WHY NOT YOU?

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**GREAT NEWS**

NOW AVAILABLE:TWO NEW FLAVORS

- Salted Caramel (Dr. Ziv Simon's Favorite)

- All Natural (No Color & No Flavor)

WITH THIS NEW INTRODUCTION,

**BUY 9, GET 1 FREE**

Any flavor combination.

**GOOD NEWS**

TheBestTopicalEver!

ALL FLAVORS ARE AVAILABLE:

FOR ALL ORDERS

**BOTH NEW & REPEAT ORDERS**,

please fill the

DENTIST FORM

below for prompt shipment.

Kindly note that only US licensed prescribers

can order TheBestTopicalEver.

In addition, we can only ship to addresses within:

CALIFORNIA, ARIZONA, NEVADA, & WASHINGTON STATE.

Online order by completing the Dentist Information Form then order below.

Thank you.

NEW & REPEAT ORDERS

DENTIST/ DOCTOR INFORMATION FORM

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How did you hear about us? (If referred, please let us know that person's name and contact, so that we may send a thank you note.)

Contact Person & Position:

Full Name of ORDERING DENTIST / DOCTOR / NP / PA: *

**(Kindly note that only US licensed prescribers are authorized to order.)

Please specify:

DEA / NPI No.:*

Licence No.:*

Licence State:*

Office / Clinic Name:

Company Website: *

Office Telephone:

Office Fax:

Cell Phone (Alternate Telephone):

Email:

SHIPPING ADDRESS 1: **(Kindly note that we are currently only licensed to ship to: AZ, CA; NV & WA)*

This may be "Care of...."

SHIPPING ADDRESS 2:*

SHIPPING CITY:*

SHIPPING STATE:*

SHIPPING ZIP CODE:*

NOTES / COMMENTS 1: ** NUMBER OF JAR (S) & FLAVOR(S)*

NOTES / COMMENTS 2: **ALL ORDERS REQUIRE ONE PATIENT NAME & DATE OF BIRTH PER JAR.** (If more than one, please use comma/space/semi-colon between patients.)*

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