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Dental Technology Specialists, Inc.

Order Acucam Supplies Here

Charge your order to your Visa, MasterCard or American Express. You can order quickly and easily by using this order form. Simply complete the form and press "Send" at the bottom.
If you prefer, you may print this order form and either fax or mail it with your payment.

Please complete all of the following information. If any information is missing, it may result in a delay in processing your order.

*Complete all required fields or your order will not go through.

Description
Price Each
Qty.
Hitachi VYSS-50 Film (50 count) $45
Hitachi VYHS-100 Film (100 count) $89
Banta Healthcare Sleeves (500 count) $95
100w Replacement Bulbs $18.50
Your name as it appears on your credit card: *required
Street Address: *required
City: *required
State: *required
Zip Code: *required
Country: *required
E-Mail Address: *required
Daytime Phone#: *required
Evening Phone #:
Fax#:
Credit Card to which we have permission to
charge your order: Select one:
*required
Credit Card Number: *required
Expiration Date: (MM/YY): *required
Please enter the shipping address if different from above, or any special requests

After completing all information, simply press "Send ".