Order Form

Complete and print the form below and send it with your payment to:

BARTH
23 Av de la Turquoise
1640 Rhode St Genese Belgique
Tel / Fax : 00 32 2 361 63 32

Your order will be processed as soon as payment is received and will be shipped to you by carrier.

Surname
First name
 
   
Delivery address
Town
Post code
Country
e-mail
Tel
Comments

Yes, I would like to receive:

Item ordered

Quantity

Unit price ( including tax)

Amount

LYRE-JET Family
Comprising 1 system
+ 3 heads
+ 30 lengths of dental floss
1 year international guarantee

30 floss refills

Additional Lyre-Jet head


Postage costs

France (postage: 31)

Europe (postage: 45)

Total order Euros


Please do not hesitate to contact us for an update on your order.