Denture Repair Services.
Denture Duplication Services.
Denture Reline Services.
One Tooth Repair
(you supply usable tooth)
Add $15 per tooth                                   x $10
One Tooth Repair
(we supply usable tooth for broken or lost tooth)
Add $15 per tooth                                   x $10
Denture Break or Fracture
Add $20 for additional break, fracture, remove glue, fix built up holes or worn areas, renew stained or discolored areas.  From $20 each.
Premium Quality Duplicate Dentures
           Upper Denture               Lower Denture
One shade lighter teeth, super white teeth, or bright white teeth
Denture Repair Warranties.
6 Month Extended Repair Warranty - Each Denture
Professional Clean + Shine + Polish
Permanent Denture (LAB) Reline
Other Services.
Place Name in Denture

City, State, Zip Code
Email Address:
Birth Day:
Credit Card Type:

Name on Credit Card:

Credit Card Number:

Expiration Date: (mm/yy):
Credit Card 3 Digit Code:
1 Year Extended Repair Warranty - Each Denture
5 Years Extended Repair Warranty - Each Denture
Each Denture
Standard Shipping and Handling (3-5 Days)
Overnight Fri. Delivered on Saturday
International - Please Call. Add $15 to rate
Plastic Storage / Shipping Container
2 Business Days
Overnight (Mon - Fri) to most areas
Dentures Shipping and Handling.
Sub Total:
Shipping and Handling:
Grand Total:
Same Day Denture Repairs. All dentures are repaired and shipped back to you within 2-4 hours from the time they are received by us. (Monday - Friday 7am - 3pm). Dentures received after 4pm will ship out next morning. Duplicate Dentures take 7-10 days to make. Your original denture is returned same day after mold is made. My denture will be examined upon arrival, and I will be contacted first if additional repair is needed. If my denture cannot be repaired, I understand my denture will be delivered to me free using standard delivery stated on including an evaluation report. All denture repairs include a free evaluation, requested repair, and 30-day warranty on the repair. 30-day warranty: I will provide Urgent Denture Repair with a copy of my proof-of-purchase along with my denture for repair. Extended warranties begin after 30-day repair warranty expires. Same applies to extended warranty.
Payment by Personal Check, Monday Order or Cashier Check. **Note: Personal Checks take 3-5 business days to clear.
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If you have any kind of trouble using this form please print it out and use your pen.
Orders, Call Toll Free:
Repair Status Call:
Master Card
American Express
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Add duplicate
denture for $199
Add duplicate
denture for $199
Add duplicate
denture for $199
Save $10
Save $10
Save $10
Cut out for mailing label
Safe $10 when you order your duplicate denture with your denture repair.
Place Phone Number in Denture
Denture reline kit    $35.     Call to order.
Denture Repair Form by Urgent Denture Repair Center. If you don't have printer please write your repair needs and attach it with your denture. We will call you and print the form at our end.