orderform

Notice: We use Diabetic Friendly's address to make sure undue attention is not focused on your GOLD!
Please fill completely for accuracy, print one for your records, send one to us!


Dental Practice Name
Office Manager
Address
City
State
Post Code
Phone
Email
Doctor's License Number

Tell us about the scrap batch:
Repeat Customer
Number of crowns
Approx weight
	Check here if amalgan included
	Does this contain bio material (teeth or blood)
	Does this order contain buttons & dental flats
	Does this contain jewelry and/or chain

Order Comments and Special Requests

Signature: __________________________________ Date:__________________

The terms and conditions contained herein shall be binding on each and every customer of Used-Gold and shall inure to the benefit of Used-gold.com's successors and assigns.

Requirements For Use

Every customer must be at least twenty-one (21) years of age in order to conduct business with Used-Gold. In addition, every customer of Used-Gold must be the actual owner of any and all property sold or attempted to be sold to Used-Gold. Used-Gold.com may, but shall not be obligated or required to, request documentation or other proof of compliance with the requirements stated above.