Congratulations. You are almost done.  

Now we need to know what we should engrave on your DentaFication® bracelet, Dog-Tag, and/or Card.

Please fill in the form below and submit it to permit the commencement of the manufacture of your personalized DentaFication® bracelet, dog tag, and/or card. 

  1. To measure your wrist, for a bracelet purchase, cut a strip lengthwise from an 81/2 X 11 piece of paper.
  2. Wrap it snugly, but not too snug, around your wrist and mark where it overlaps.
  3. Straighten out the strip of paper and measure. That is your wrist size.
  4. We will add approximately 1/4 inch for your comfort on those puffy days.


As a part of this sale, and to further promote the safety, health, and welfare of society, if you desire, a donation will be made in your name to one of the following charities. Simply select the charity of your choice at the bottom of this form, and the deed will be done.

1.  Cancer Research Institute
2.  American Society for the Prevention of Cruelty to Animals ASPCA
3.  American Red Cross
4.  Guide Dog Foundation for the Blind
5.  National Council on Aging


* Your Name
* Your Date of Birth:
* Your Phone #:
* Your Email:
* Your Street Address & Apt #
* Your City, State, Zip, & Country
* Your Dentist's license # & State OR his/her Name and address
Your personal contact's name & phone #:
* Dentafication® model #:
If a bracelet, your wrist size:
If a bracelet, which wrist will you wear it on? Right
If a Card, include my head-shot that I will email. Yes
* List your illnesses:
* List your allergies:
Any Comments?
Pick a Charity (Optional) Cancer Research
Red Cross
Guide Dogs for the Blind
Council on Aging
Contact me by:
I am buying this for: