Order Form

Use this page to Order your Mercury Safe Education Add-On. Please completely fill this out click on the blue button at bottom. 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.

 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 the URL of your website's home page.)

(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.)

(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.)

(Leave this blank if you don't have or want additional partner names to appear on the Add-On pages. Otherwise, list the last names of your partners here. Their names will also appear on the customized Add-On pages. If more than one name, separate them with commas.)

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

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

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

(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.)

 Male    Female    Other   

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

(Check this box if you are IAOMT SMART certified.)
  Prove you're human! Help us to avoid SPAM and enter the characters below:
    

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