ORDER FORM
| Complete and print order form. Credit card information is optional and can be obtained over the phone once denture is recieved. Shipping to the lab is free with prepaid label. Overnight shipping is suggested. We ship back with free overnight mail. | ||||
| Mail to: Denture Repair Lab | 1006 Charles St Ste 4 | N. Providence RI 02904 |
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  First Name Last Name Phone * |
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| Address | ||||
| City | ||||
  Money Order |
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| Credit Card # |
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| Signature:___________________________________________
I have read and agree to the Denture Repair Lab Policy and authorize Denture repair Lab to charge my credit card for the services provided. |
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 Glue Removal $29.00 Metal Reinforcement $29.00 Rebuild Gum Area w/ New Acrylic $169.00 |
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| 1 Crack/Break/Fracture $79.00 2 Cracks/Breaks/Fractures $115.00 3 Cracks/Breaks/Fractures $145.00 |
Duplicate Denture $299 / Duplicate Partial $349.00 Professional Cleaning & Polishing $49.00 90 Day Warranty $45.00 |
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 Glue Removal $29.00 Metal Reinforcement $29.00 Rebuild Gum Area w/ New Acrylic $169.00 |
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| 1 Tooth (you supply tooth) $75.00 2 Teeth (you supply teeth) $95.00 3 Teeth (you supply teeth) $115.00 |
1 Tooth ( lab supply teeth) $95.00 2 Teeth (lab supply teeth) $125.00 3 Teeth (lab supply teeth) $165.00 |
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| Duplicate Denture $299 / Partial $349.00 Cleaning /Polishing $49.00 90 Day Warranty $45.00 | ||||
 Glue Removal $29.00 Metal Reinforcement $29.00 |
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| 1 Crack/Break/Fracture $219.00 2 Cracks/Breaks/Fractures $259.00 |
1 Tooth (you supply) $175.00 2 Teeth (you supply) $205.00 |
1 Tooth (lab supply) $195.00 2 Teeth (lab supply) $225.00 |
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| Duplicate Partial $349.00 Cleaning & Polishing $49.00 90 Day Warranty $75.00 | ||||
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| Duplicate Denture $299.00 Duplicate Partial (non metal) $349.00 Duplicate Hard Nightguard $199.00 |
1Shade Whitter Teeth $35.00 Cleaning & Polishing $49.00 90 Day Warranty $45.00 |
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Coupon Code
TOTAL
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Additional Instructions
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| Please mail you denture to: Denture Repair Lab 1006 Charles St Ste 4 North Providence RI 02904 |
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