PROFESSIONAL ORDER FORM - Waterpik
PROFESSIONAL ORDER FORM - Waterpik
PROFESSIONAL ORDER FORM - Waterpik
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<strong>PROFESSIONAL</strong> <strong>ORDER</strong> <strong>FORM</strong><br />
TOLL-FREE 1-800-525-2020 (OPTION 3) FAX 1-800-289-4389<br />
Water Pik, Inc.<br />
1730 East Prospect Road<br />
Fort Collins, CO 80553-0001<br />
www.professional.waterpik.com<br />
Date_________________________________________<br />
B<br />
ILL<br />
T<br />
O<br />
Name _________________________________________________________ o DDS o DMD o RDH o MD<br />
Address _____________________________________________________________________________________________<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _<br />
City____________________________________________________________ State__________ Zip_______ ____________<br />
S<br />
E<br />
N<br />
D<br />
T<br />
O<br />
Name __________________________________________________________ o DDS o DMD o RDH o MD<br />
Address ______________________________________________________________________________________________<br />
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City_______________________________________________________________ State__________ Zip_______ __________<br />
Telephone _________________________________________________________________________________________<br />
Telephone __________________________________________________________________________________________<br />
Charge to: Card # _________________________________________________________ Exp ______________ __ o VISA o MasterCard o AMEX o Discover<br />
Prices effective May 1, 2009 and are subject to change without notice.<br />
(Acceptance of order subject to credit approval.) All orders require credit card. No Checks Please.<br />
Place Order in Case Quantities Only.<br />
QTY. Price Levels Price/Unit Total<br />
<strong>Waterpik</strong> ® Ultra Dental Water Jet (WP-100W)<br />
<strong>Waterpik</strong> ® Ultra Dental Water Jet features a contemporary, compact design, a pressure<br />
control system with 10 settings and a covered reservoir with built-in storage. Two jet<br />
tips, one tongue cleaner, one Pik Pocket TM tip, one orthodontic tip and one toothbrush<br />
tip included. Units per case: 3. Suggested Patient Price $49.99<br />
<strong>Waterpik</strong> ® Ultra Cordless Dental Water Jet (WP-450W)<br />
<strong>Waterpik</strong> ® Ultra Cordless Dental Water Jet features a new ergonomic design<br />
and a specially-designed orthodontic tip, and is perfect for patients with braces.<br />
One jet tip, one orthodontic tip, one Pik Pocket TM tip, and one tongue cleaner tip<br />
included. Units per case: 2. Suggested Patient Price $44.99<br />
<strong>Waterpik</strong> ® Personal Dental Water Jet (WP-60W)<br />
<strong>Waterpik</strong> ® Personal Dental Water Jet features flow control on handle.<br />
Reservoir measuring guide for water, mouthwash or antibacterial solutions.<br />
One jet tip and one tongue cleaner attachment included.<br />
Units per case: 6. Suggested Patient Price $34.99<br />
<strong>Waterpik</strong> ® Cordless Dental Water Jet (WP-360W)<br />
<strong>Waterpik</strong> ® Cordless Dental Water Jet features convenient, hand-held design.<br />
Tips rotate 360°. Rechargeable, no batteries required. Comes with one low<br />
pressure jet tip and one medium/high pressure jet tip.<br />
Units per case: 2. Suggested Patient Price $29.99<br />
<strong>Waterpik</strong> ® Sensonic ® Professional Toothbrush (SR-1000W)<br />
<strong>Waterpik</strong> ® Sensonic ® Professional Toothbrush with superior plaque removal, ergonomic<br />
no slip grip handle design. Features a 2 minute timer with 30 second quadrant indicator,<br />
2 brush speeds, 1 advanced and 1 compact extra-soft, end-rounded bristle brushes, 1<br />
interdental brush. Units per case: 2. Suggested Patient Price $69.99<br />
<strong>Waterpik</strong> ® Power Flosser (FLA-220)<br />
<strong>Waterpik</strong> ® Power Flosser provides 10,000 strokes per minute, is easy to use,<br />
quick and convenient. Includes AA battery and 15 disposable flossing tips.<br />
Units per case: 3. Suggested Patient Price $5.99<br />
<strong>Waterpik</strong> ® Power Whitening Flosser (FLW-110)<br />
<strong>Waterpik</strong> ® Power Whitening Flosser provides 10,000 strokes per minute, is easy to<br />
use, quick and convenient. Includes 45 mint-flavored tips coated with a whitening<br />
agent and two hygienic sleeves. Units per case: 3. Suggested Patient Price $11.99<br />
<strong>Waterpik</strong> ® Ultra Replacement Jet Tips (JT-100E)<br />
Jet tips for <strong>Waterpik</strong> ® Ultra (WP-100). Two-pack.<br />
Packs per case: 5. Suggested Patient Price $7.99<br />
3-9 UNITS 42.49<br />
12+ UNITS 37.49<br />
2-10 UNITS 38.24<br />
12+ UNITS 33.74<br />
6 units 29.74<br />
12+ UNITS 26.24<br />
2-10 units 25.49<br />
12+ UNITS 22.49<br />
2-10 UNITS 59.49<br />
12+ UNITS 52.49<br />
3-9 UNITS 5.09<br />
12+ UNITS 4.49<br />
3-9 UNITS 10.19<br />
12+ packS 8.99<br />
5-10 CARDS 6.79<br />
15+ CARDS 5.99<br />
PLEASE SEND ME:<br />
_____ FREE Patient Education Brochures. (Packs of 50). Item #20008658-SSH<br />
_____ Please go to www.professional.waterpik.com to view our educational video options.<br />
Fax or mail completed form to:<br />
Water Pik, Inc. Professional Customer Service<br />
1730 East Prospect Road<br />
Fort Collins, CO 80553-0001<br />
Water Pik, Inc. manufactures products only to its own commercial specifications and sells only on commercial terms and conditions. Accordingly, Water Pik, Inc.<br />
expressly rejects any additional specifications, procurement regulations, or additional warranties unless they are negotiated and mutually agreed upon before<br />
shipment. Purchaser’s acceptance of the product constitutes an acknowledgement of these terms.<br />
**<strong>Waterpik</strong> ® Dental Water Jet Models WP-100W, WP-450W, WP-60W, WP-360 and SR-1000W carry a 2 year limited warranty.<br />
<strong>ORDER</strong> <strong>FORM</strong> CONTINUED ON OTHER SIDE.<br />
STANDARD DELIVERY RATES<br />
<strong>ORDER</strong> AMOUNT<br />
FREIGHT CHARGE<br />
Under $300 $7.95<br />
$300.01 - $999.99 $10.95<br />
$1,000 - $3,000 $24.95<br />
Over $3,000<br />
1% of invoice
WATERPIK <strong>PROFESSIONAL</strong> <strong>ORDER</strong> <strong>FORM</strong><br />
Place Order in Case Quantities Only.<br />
Continued from other side.<br />
QTY. Price Levels Price/Unit Total<br />
<strong>Waterpik</strong> ® Ultra Cordless Replacement Jet Tips (JT-450E)<br />
Jet Tip for <strong>Waterpik</strong> ® Ultra Cordless (WP-450) and High Pressure Jet Tip replacement<br />
for <strong>Waterpik</strong> ® Cordless (WP-360). Packs per case: 5. Suggested Patient Price $7.99<br />
<strong>Waterpik</strong> ® Cordless Replacement Jet Tips (JT-360E)<br />
Low-Pressure Jet Tip (blue) for <strong>Waterpik</strong> ® Cordless (WP-360). Two-pack.<br />
Packs per case: 5. Suggested Patient Price $7.99<br />
<strong>Waterpik</strong> ® Replacement Toothbrush Tips (TB-100E)<br />
New<br />
Toothbrush Tips for <strong>Waterpik</strong> ® WP-100, WP-450.<br />
Two-pack. Packs per case: 5. Suggested Patient Price $7.99<br />
5-10 CARDS 6.79<br />
15+ CARDS 5.99<br />
5-10 CARDS 6.79<br />
15+ CARDS 5.99<br />
5-10 CARDS 6.79<br />
15+ CARDS 5.99<br />
<strong>Waterpik</strong> ® Replacement Orthodontic Tips (OD-100E)<br />
Orthodontic Tip for <strong>Waterpik</strong> ® WP-100, WP-450.<br />
Packs per case: 5. Suggested Patient Price $7.99<br />
5-10 CARDS 6.79<br />
15+ CARDS 5.99<br />
<strong>Waterpik</strong> ® Replacement Pik Pocket TM Tips (PP-100E)<br />
Pik Pocket TM Tip for <strong>Waterpik</strong> ® WP-100, WP-450. Two-pack.<br />
Packs per case: 5. Suggested Patient Price $7.99<br />
5-10 CARDS 6.79<br />
15+ CARDS 5.99<br />
<strong>Waterpik</strong> ® Replacement Tongue Cleaner Tips (TC-100E)<br />
Tongue Cleaner Tip for <strong>Waterpik</strong> ® WP-100, WP-450, WP-360.<br />
Tips per card: 2. Cards per case: 5. Suggested Patient Price $7.99<br />
5-10 CARDS 6.79<br />
15+ CARDS 5.99<br />
<strong>Waterpik</strong> ® Sensonic ® Professional Replacement Advanced Brushes (2SRB-2W)<br />
Standard Brushes for Sensonic ® Professional Toothbrush Model SR-1000W.<br />
(2 pack color-coded brushes). Cards per case: 5. Suggested Patient Price $8.99<br />
5-10 CARDS 7.64<br />
15+ CARDS 6.74<br />
<strong>Waterpik</strong> ® Sensonic ® Professional Replacement Compact Brushes (SRSB-2)<br />
Compact Brushes for Sensonic ® Professional Toothbrush Model SR-1000W.<br />
(2 pack color-coded compact brushes)<br />
Cards per case: 5. Suggested Patient Price $8.99<br />
5-10 CARDS 7.64<br />
15+ CARDS 6.74<br />
<strong>Waterpik</strong> ® Sensonic ® Professional Replacement Interdental Brushes (2SIP-2W)<br />
Interdental Brushes for Sensonic ® Professional Toothbrush Model SR-1000W.<br />
(2 pack color-coded interdental brushes).<br />
Cards per case: 5. Suggested Patient Price $8.99<br />
5-10 CARDS 7.64<br />
15+ CARDS 6.74<br />
<strong>Waterpik</strong> ® Power Flosser Whitening Replacement Tips (FTW-01)<br />
30 disposable mint-flavored whitening tips.<br />
Use with Models FL-110, FLW-110, FLA-220 and FLW-310.<br />
Cards per case: 6. Suggested Patient Price $4.99<br />
6 CARDS 4.24<br />
12+ CARDS 3.74<br />
<strong>Waterpik</strong> ® Power Flosser Replacement Tips (FT-01)<br />
30 disposable flossing tips.<br />
Use with Models FL-110, FLW-110, FLA-220 and FLW-310.<br />
Cards per case: 6. Suggested Patient Price $3.99<br />
6 CARDS 3.39<br />
12+ CARDS 2.99<br />
<strong>Waterpik</strong> ® Replacement Jet Tips (JT-70E)<br />
Jet Tip replacement tips for WP-60, WP-65, WP-70, WP72, WP-75.<br />
Tips per card: 2. Cards per case: 5. Suggested Patient Price $7.99<br />
5-10 CARDS 6.79<br />
15+ CARDS 5.99<br />
<strong>Waterpik</strong> ® Replacement Pik Pocket TM Tips (PP-70E)<br />
Pik Pocket TM replacement tips for WP-60, WP-65, WP-70, WP72, WP-75.<br />
Tips per card: 2. Cards per case: 5. Suggested Patient Price $7.99<br />
5-10 CARDS 6.79<br />
15+ CARDS 5.99<br />
<strong>Waterpik</strong> ® Replacement Tongue Cleaner Tips (TC-70E)<br />
New<br />
Tongue Cleaner replacement tips for WP-60, WP-65, WP-70, WP72, WP-75.<br />
Tips per card: 2. Cards per case: 5. Suggested Patient Price $7.99<br />
5-10 CARDS 6.79<br />
15+ CARDS 5.99<br />
Subtotal From This Side<br />
FN 20010233OPD-F AK • PN 20010233-OPD
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