Your Smile!

[Dr.Kelly.LeBlanc@xwing.aoltw.net]

Kelly LeBlanc, DDS
Cosmetic and Preventive 
Dentistry
more info 
springdentist@GetResponse.com or 
281-376-3959

My name is Kelly LeBlanc, DDS and 
I have developed a bleaching tray 
system to whiten your upper and 
lower teeth for only $99!

Imagine brightening your stained 
teeth 5-10 times whiter in just a 
couple of weeks! It's really that easy.

This is not some over-the-counter 
store bought bleaching kit.

This is the same bleaching kit I sell 
in my office in Houston, Texas for 
$350.  The reason I can do this for 
only $99 is a unique dual tray design 
that lets you make your custom 
bleaching trays yourself at home.

The reason dentists charge so much 
for bleaching teeth is the high 
overhead in the office of taking 
impressions of your teeth and 
making the trays and high salaries 
of dental employees.

Visit our web site to learn much 
more information on how this new 
easy way of whitening your smile will 
work for you!
For our web site send a blank email 
to 
springdentist@GetResponse.com.

Ordering information is below.  Just 
fax the completed form to our office 
at 281-356-7935 or email the order 
form to 
springdentist@GetResponse.com.

Teeth Whitening at this price also 
makes a great gift for a friend or 
loved one for the holidays!

PRINTABLE ORDER FORM BELOW



INTERNET BLEACHING ORDER FORM:
To complete your order, our bank requires that all customers fill out this 
form below and fax it back to us at 281-356-7935.  Please print this form 
and fill it out completely.  Soon after we receive your faxed form, we will fax 
you back a confirmation on your order.

Customer Name:___________________________________________

Customer Address:_________________________________________

City:____________________ State___________ Zip:______________

Type of Credit Card:    ______ Visa    _____ Mastercard   ______AMEX   
______DISC

Name on Card: _____________________________________________
Credit Card Number: _________________________________________
Expiration:_________________
Place the number of Teeth Bleaching Kits you would like, i.e., the number of 
people that will want to Bleach their teeth ______   X $99 per 
kit=___________Total $ amount charged to card.
I, _________________________ am an authorized user of the above 
charge card. (Print full name). I authorize Kelly M. LeBlanc, DDS to charge 
a total of $_________ to my charge card. 
By accepting this product, you agree that you:
- Will use the trays for the sole purpose of whitening your teeth and will 
discontinue use if you experience sensitivity.
- Will not use the product if you are pregnant or nursing until you have 
consulted with your dentist.
- Don't have loose or decayed teeth.
- Don't have loose crowns or periodontal problems (gum disease).
- Will consult with a dentist if you experience any problems while using this 
product.
- Acknowledge that this will not whiten any dental work (crowns, veneers, 
cavities, bridges, etc.).
- Are not allergic to sodium fluoride, carbamide peroxide, 
glycerin,carbome, sodium hydroxide, flavor, hydrogen peroxide, 
ammonium, hydroxide, and silicone.
- Will completely read ALL directions enclosed and call Dr.LeBlanc's office 
if you have any questions.
Allow 2 weeks for delivery
Signature (required): 
___________________________________________________
THANK YOU FOR YOUR ORDER!!

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