The Collis-Curve (TM) Toothbrush   
Order Form & Order Information

6110 California Road, Brownsville, TX, 78521  Ph: 800-298-4818  Fx: 956-546-4818
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Phone Fax Email
Dial: 1-800-298-4818 1. Print out this page
2. Fill in all the information
3. Fax to: 1-956-546-4818
1. Click on this address
2. Submit your order with only
   half your credit card number
3. Submit another email with re-
   maining credit card number
  
Ship To:
Name:  
Address:  
City:   State/Prov:   Zip:  
Phone:   Fax:   Email:  
  
Item: # 4 Pack # 13 Pack Total
Medium (adult size)   x $24.99   x $59.99  
Soft (gentle, 9yrs+)   x $24.99   x $59.99  
Perio (longer bristles)   x $24.99   x $59.99  
Youth (under 9yrs)   x $24.99   x $59.99  
Baby (6 mths - 5yrs)   x $24.99   x $59.99  
**NEW Item #

One Electric toothbrush base with 4 curved bristle replacement heads

 
Electric Toothbrush   x $24.99  
Sales Tax: TX add 8.25%  
FREE shipping on all orders Grand Total:  
  
Credit Card Information:
Name on Card:  
Card Number:  
Expiration Date:  
Cardholder Signature:   Date:  


Send your check or money order in US funds to:

Collis-Curve Toothbrush Catalog
6110 California Road
Brownsville, TX  87521
Ph/fax 800-298-4818
Fx: 956-546-4818
Em: brushteeth@aol.com

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