Dental Herb Company®Inc.

Boca Raton, FL  33487

Patient Information

Dental Herb Company® does not accept telephone inquires from patients. Please communicate with us via e-mail by completing the following questionnaire. We will then send you Patient Literature and Pricing Information. Dental Herb Company® only accepts inquiries from patients in the Continental United States.

Dental Herb Company® products are sold through dental offices.

There are two ways for patients to obtain them:

1. Purchase from your dentist

2. DHCo® PATIENT REFERRAL PROGRAM
Ask your dentist to FAX us a short note on their letterhead, stating your are a patient of record, and giving permission for us to sell products directly to you.

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The Patient Referral Letter must be:

  1. Written on office letterhead
  2. Dated
  3. Signed by the Dentist only (not staff)
  4. Please make sure that we have your contact information – which can be submitted via the Patient Link at www.dentalherbcompany.com
  5. Please have the dentist use the following language:

(First & Last Name) is a patient of record. 

I give permission for (patient name) to purchase Dental Herb Company® products directly from Dental Herb Company®.

***Please Note: If the patient wishes to use “Under the Gums Irrigant®” the letter must additionally state:

"including Under the Gums Irrigant®”

Please FAX referral to (561) 241-4480.
As soon as we receive the FAX, we will contact you and take your order.


Required Fields are indicated by an asterisk*.

Name:*

Address:*

City:*

State/Province:*

Zip/Postal Code:*

Daytime Phone(s):*
Email Address:*

 

How did you hear about Dental Herb Company® Products?*     

 

Have you ever used Dental Herb Company® Products?*     
If so, which products have you used?*

 

 

Where did you obtain the Products?*     

 

Are you currently using Dental Herb Company® Products?*     

If so, which products are you using?*     

 

Where are you obtaining the products?*     

 

Are you currently under the care of a dentist?*     

If so, what is your dentist’s name (optional)?

 

What is the dentist’s telephone number (optional)?

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