1. Choose your design style from Product Gallery and put Style number.
  2. If special style, please design in picture below with full detail
  3. Print out and mail completed form with Money Order or Cashers check along with the completed mold (Do not remove the mold from the tray!)
    To: Mr. Gold Teeth
          3855 E. Pikes Peak Ave.
          Colorado Springs, CO 80909
          Phone: 719-572-5379 / 866-572-5379
  4. Please allow completed Gold Teeth to get delivered within 3-10 days.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name: _______________________________________________________________________________

Address: _____________________________________________________________________________

____________________________________________________________________________________

Phone: (                         ) ________________________________________________________________ 

Gold Teeth Style Number (can be found next to Gold Teeth sample picture):______________

Gold Teeth Design. ( ** If you have special design request, please draw your design below.)


Special Request  _______________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

 

Step Description Quantity Total
 
#1  Molding Kit. $30 each
 (How many Molding kit do you need?)		     $
 
#2  Gold Teeth
 (Check the color! How many gold teeth do you want?)		    
  (Yellow / White) 10K, $30 each       $
(Yellow / White) 14K, $40 each       $
(Yellow) 18K, $60 each       $
Platinum, $200 each       $
 
#3 Stone
(Please indicate what kind of stone and quantity you want)		    
   1 Point Diamond, $10/Stone     $
 2 Point Diamond, $20/Stone     $
 Birthstone  $10 each   $
 Letter/Initial $10 each   $
 Vampire Fang $10 each   $
 Diamond Cut $5 each   $
#4  Subtotal
(Please add Total from Box #1 to Box #3)		     $
 

Colorado residents should pay sales tax!

     $
 

S&H (Priority $5; Express $15; Global Priority $10)

     $

Total Amount

   $
 
** Mr. GoldTeeth.com recommends payments to be sent via
   priority mail with delivery/signature confirmation or express mail.
** Please, keep a record of your money order number to ensure proper tracking of payments.
** You can make a quick payment using your credit card via PayPal service.
It is on the right side of the home page.
** We accept international orders. Please send us an email to check the S/H cost.

Please mail out completed form with Money Order, Cashers check or PayPal payment confirmation along with the completed mold (Do not remove the mold from the tray!)
To: Mr. Gold Teeth
      3855 E. Pikes Peak Ave.
      Colorado Springs, CO 80909
      Phone: 719-572-5379