CHECKOUTTEST 1. Initial Payment (1) Step 1 of 6 16% Payment Method(Required) Credit Card PayPal Apple Pay Google Pay Amazon Pay Payment Preference(Required)(Note: NowDenture Heat and Fit Only Available With “Pay in Full”.) Pay in Full Today Pay in Four Payments (first payment today, then every two weeks) Product SelectionProduct Pay in Full(Required) Upper NowDenture (Heat and Fit) Lower NowDenture (Heat and Fit) Upper & Lower NowDenture (Heat and Fit) Upper & Lower Partial Upper Partial Lower Partial Upper & Lower Denture (Custom Made) Upper Denture (Custom Made) Lower Denture (Custom Made) Upper Partial & Lower Denture Upper Denture & Lower Partial Dental Flipper 1-2 Teeth Upper Dental Flipper 1-2 Teeth Lower Nesbit Product Pay in Four(Required)Note: The Heat & Fit NowDenture is pay in full only. Upper & Lower NowDenture (Heat and Fit) Upper NowDenture (Heat and Fit) Lower NowDenture (Heat and Fit) Upper Denture (Custom Made) Lower Denture (Custom Made) Upper & Lower Denture (Custom Made) Upper Partial Lower Partial Upper & Lower Partial Upper Partial & Full Lower Upper Denture & Lower Partial Dental Flipper 1-2 Teeth Upper Dental Flipper 1-2 Teeth Lower Nesbit (Pay in Two) Upper Partial Type(Required) Flexible (no added charge) Metal Visiclear Upper Partial Type(Required) Flexible (no added charge) Metal Visiclear Upper Partial Type(Required) Flexible (no added charge) Metal Visiclear Upper Partial Type(Required) Flexible (no added charge) Metal additional per payment Visiclear additional per payment Upper Partial Type(Required) Flexible (no added charge) Metal additional per payment Visiclear additional per payment Upper Partial Type(Required) Flexible (no added charge) Metal additional per payment Visiclear additional per payment Lower Partial Type(Required) Flexible (no added charge) Metal Visiclear Lower Partial Type(Required) Flexible (no added charge) Metal Visiclear Lower Partial Type(Required) Flexible (no added charge) Metal Visiclear Lower Partial Type(Required) Flexible (no added charge) Metal additional per payment Visiclear additional per payment Lower Partial Type(Required) Flexible (no added charge) Metal additional per payment Visiclear additional per payment Lower Partial Type(Required) Flexible (no added charge) Metal additional per payment Visiclear additional per payment This field is hidden when viewing the formNesbit Upper or Lower(Required) Upper Lower How many teeth are needed for this partial?(Required)Select5 or less6 or moreUpperHow many teeth are needed for this partial?(Required)Select5 or less6 or moreUpperHow many teeth are needed for this partial?(Required)Select5 or less6 or moreLowerHow many teeth are needed for this partial?(Required)Select5 or less6 or moreLowerPlease Note:(Required) There is a one time additional charge of $60 for partials of 6 teeth or more. Please Note:(Required) There is an additional charge of $15 per payment for partials of 6 teeth or more. This field is hidden when viewing the formAre any of your teeth broken?NoneSomeAllThis will help us prepare for your new smile. NowDenture Size(Required) Extra Large (Larger than the average sized man) Large (Average man) Medium (Average woman) Small (Smaller than the average sized woman) Next Day Air Rush Shipping & Processing $60* No Yes *Available for orders M-F before 2pm (EST). If selected after 2pm (EST) orders will ship out on the next business day via Next Day Air. (Holidays excluded. First Shipment Only) Next Day Air Rush Shipping & Processing $60* No Yes *Available for orders M-F before 2pm (EST). If selected after 2pm (EST) orders will ship out on the next business day via Next Day Air. (Holidays excluded. First Shipment Only) Next Day Air Rush Shipping & Processing $60* No Yes *Available for orders M-F before 2pm (EST). If selected after 2pm (EST) orders will ship out on the next business day via Next Day Air. Payable $15 with each Pay in Four Payment. (Holidays excluded. First Shipment Only) Payment InformationCredit Card Information(Required)Feed Required: To use the Stripe field, please create a Stripe feed for this form. 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(Optional)Due Today: I accept the terms and conditions.(Required) Yes You can review the full terms on the bottom of this page.Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name ***After submitting your order below please wait up to 10 seconds for processing.*** Δ
