Amalgam order form - 3 Easy steps
 

 

 


 

 

 

 

At Amalgaway, WE SAY YES!  |  OFFLINE Ordering Options

Step 1 - Products

 
Quantity Needed:
 Item Description
Amalgam - 1 Gallon Mail Disposal Kit - $115.00 each
Amalgam - 2.5 Gallon Mail Disposal Kit - $139 each
Amalgam - 5 Gallon Mail Disposal Kit - $249 each
Small Lead Foil Mail Disposal Kit - $45 each
Large Lead Foil Mail Disposal Kit - $75 each
Model CH 12 Amalgam Collector™ Separator - $595 each
Model CE 18 Amalgam Collector™ Separator - $825 each
Model CE 24 Amalgam Collector™ Separator - $1,245 each
Auto Siphon - $375 each
   
Step 2 - Shipping  *BOLD REQUIRED
First & Last Name:  
Company / Name of Practice:  
Street Address
(No PO Boxes)		  
Phone:  
Email:  
   
Dental Association:  
PO Number:
(if applicable)		  
   
Step 3 - Payment  
Pay By:
If paying by credit card, please fill out the following information:  
Credit Card Type:
Credit Card Number:  
CVV Number (on back of card):
Billing Address Information: (only fill out if different than shipping address)
First & Last Name:
Company / Name of Practice:
Street Address:
Phone:
Email:
   
Dental Association:
PO Number:
(if applicable)
   
Other Order Info:
 

 


 


 

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