Order Form

Use this page to order one of the MSEA options. Please fill out this order form and click on the blue button. You will then be taken to our secure shopping cart where you can complete your order. If you have any problems filling out the order form, please contact us here.

Mercury Safe Education Add-On ($995)

Mercury Safe Education Add-On
$995

Dr. Tom's Mercury Safe Directory

Already Listed Please Add Me Not Interested

(If you're already on Dr. Tom's Mercury Safe Dentist Directory you'll receive a $100 discount at Checkout. If you're not listed on the Directory and would like to be added at this time, you'll also get a 50% Discount for the 1st Year at checkout – a $ 225 Savings!)

Enter Your Home Page URL

(Enter the URL of your website's home page.)

Web Person's Email Address

(Please enter the email address of your web person or person who will add the link from your website to the new MSEA pages we created for you.)

Web Person's Name

(Please enter the name of your web person or person who will add the link from your website to the new MSEA pages we created for you.)

Enter Your First Name

(Your first name as you wish it to appear on the Add-On pages.)

Enter Your Last Name

(The last name you as wish it to appear on the Add-On pages.)

Enter Your Degree

(Enter the degree you wish to see appear after your name.)

Enter Your Email Address

(Enter an email address we can use to confirm your order. This email address will not be used for marketing and will not be placed on a mailing list.)

Enter Gender

Male Female Other

(Gender is required in order for us to personalize your new Add-On pages.)

SMART Certified

(Check this box if you are IAOMT SMART certified.)

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If you have any questions about ordering an Add-On click here to contact us.