Order Form

Complete and print the form below and send it with your cheque made out 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 floss
1 year international guarantee
30 floss refills
Additional Lyre-Jet head

Postage costs
France (postage: € 31)
Europe (postage: € 45)
Total order Euros
Total order Francs


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