Order Form

Order Form

Questions? +1 800-276-6129

Note: Complete order form and click print button to print out the form. Credit card information is optional we can obtain it over the phone once denture is recieved. Shipping is free with prepaid label. Overnight shipping is suggested. We ship back with free USPS Priority mail. Upgrade to USPS Express for $25.

Mail to: Tristate Dental Lab | 2418 West 2nd Street Chester | PA. 19013

Customer Information
First Name
Last Name
Email
Phone No.
Address
City
State
Zipcode
Payment Information
payment option
payment option
payment option
payment option
payment option
Credit Card
Expiration /
CVV (3 Digit Code)
Denture / Partial Repair
Teeth Repair
Flexible Partial Repair
Duplicate Denture / Partial
Total
Total Payable Amout
$ 200.00
Additional Information
Any Instructions
Print Order Form
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