Patient ID:

Patient Name:

Invoice Date

Qty Item Number Item Description Price Ext Price

JASK Dental ClinicAddress Line 1

Address Line 2

City, State - ZipCodeCountry

ABC0001

123456

09/26/2012

1 ITEM1 Product Description - SIZE 1 1.17 1.172 ITEM2 Product Description - SIZE 2 9.86 19.723 ITEM3 Product Description - SIZE 3 9.34 28.024 ITEM4 Product Description - SIZE 4 7.13 28.525 ITEM5 Product Description - SIZE 5 2.05 10.256 ITEM6 Product Description - SIZE 6 0.89 5.347 ITEM7 Product Description - SIZE 7 3.54 24.788 ITEM8 Product Description - SIZE 8 1.55 12.409 ITEM9 Product Description - SIZE 9 3.26 29.34

10 ITEM10 Product Description - SIZE 10 3.63 36.3011 ITEM11 Product Description - SIZE 11 9.12 100.3212 ITEM12 Product Description - SIZE 12 8.61 103.3213 ITEM13 Product Description - SIZE 13 8.50 110.5014 ITEM14 Product Description - SIZE 14 7.84 109.7615 ITEM15 Product Description - SIZE 15 0.79 11.8516 ITEM16 Product Description - SIZE 16 7.57 121.1217 ITEM17 Product Description - SIZE 17 3.83 65.1118 ITEM18 Product Description - SIZE 18 2.56 46.0819 ITEM19 Product Description - SIZE 19 3.18 60.4220 ITEM20 Product Description - SIZE 20 3.11 62.2021 ITEM21 Product Description - SIZE 21 9.30 195.3022 ITEM22 Product Description - SIZE 22 5.71 125.6223 ITEM23 Product Description - SIZE 23 6.64 152.7224 ITEM24 Product Description - SIZE 24 3.08 73.9225 ITEM25 Product Description - SIZE 25 2.28 57.0026 ITEM26 Product Description - SIZE 26 3.37 87.6227 ITEM27 Product Description - SIZE 27 0.91 24.5728 ITEM28 Product Description - SIZE 28 1.90 53.2029 ITEM29 Product Description - SIZE 29 0.35 10.1530 ITEM30 Product Description - SIZE 30 5.42 162.6031 ITEM31 Product Description - SIZE 31 5.08 157.4832 ITEM32 Product Description - SIZE 32 7.65 244.8033 ITEM33 Product Description - SIZE 33 9.32 307.5634 ITEM34 Product Description - SIZE 34 4.10 139.4035 ITEM35 Product Description - SIZE 35 8.87 310.4536 ITEM36 Product Description - SIZE 36 1.67 60.1237 ITEM37 Product Description - SIZE 37 0.02 0.7438 ITEM38 Product Description - SIZE 38 6.53 248.14

Page No. 1

Patient ID:

Patient Name:

Invoice Date

Qty Item Number Item Description Price Ext Price

JASK Dental ClinicAddress Line 1

Address Line 2

City, State - ZipCodeCountry

ABC0001

123456

09/26/2012

39 ITEM39 Product Description - SIZE 39 3.21 125.1940 ITEM40 Product Description - SIZE 40 9.83 393.2041 ITEM41 Product Description - SIZE 41 7.73 316.9342 ITEM42 Product Description - SIZE 42 0.38 15.9643 ITEM43 Product Description - SIZE 43 7.84 337.1244 ITEM44 Product Description - SIZE 44 3.35 147.4045 ITEM45 Product Description - SIZE 45 0.12 5.4046 ITEM46 Product Description - SIZE 46 4.52 207.9247 ITEM47 Product Description - SIZE 47 9.91 465.7748 ITEM48 Product Description - SIZE 48 5.64 270.7249 ITEM49 Product Description - SIZE 49 2.25 110.2550 ITEM50 Product Description - SIZE 50 2.56 128.0051 ITEM51 Product Description - SIZE 51 0.15 7.6552 ITEM52 Product Description - SIZE 52 8.53 443.5653 ITEM53 Product Description - SIZE 53 2.58 136.7454 ITEM54 Product Description - SIZE 54 8.18 441.7255 ITEM55 Product Description - SIZE 55 2.89 158.9556 ITEM56 Product Description - SIZE 56 7.80 436.8057 ITEM57 Product Description - SIZE 57 9.97 568.2958 ITEM58 Product Description - SIZE 58 5.29 306.8259 ITEM59 Product Description - SIZE 59 1.66 97.9460 ITEM60 Product Description - SIZE 60 3.16 189.6061 ITEM61 Product Description - SIZE 61 9.56 583.1662 ITEM62 Product Description - SIZE 62 5.00 310.0063 ITEM63 Product Description - SIZE 63 4.95 311.8564 ITEM64 Product Description - SIZE 64 2.16 138.2465 ITEM65 Product Description - SIZE 65 5.28 343.2066 ITEM66 Product Description - SIZE 66 3.95 260.7067 ITEM67 Product Description - SIZE 67 5.58 373.8668 ITEM68 Product Description - SIZE 68 1.27 86.3669 ITEM69 Product Description - SIZE 69 7.28 502.3270 ITEM70 Product Description - SIZE 70 5.30 371.0071 ITEM71 Product Description - SIZE 71 2.71 192.4172 ITEM72 Product Description - SIZE 72 9.72 699.8473 ITEM73 Product Description - SIZE 73 5.71 416.8374 ITEM74 Product Description - SIZE 74 4.67 345.5875 ITEM75 Product Description - SIZE 75 7.70 577.5076 ITEM76 Product Description - SIZE 76 3.21 243.96

Page No. 2

Patient ID:

Patient Name:

Invoice Date

Qty Item Number Item Description Price Ext Price

JASK Dental ClinicAddress Line 1

Address Line 2

City, State - ZipCodeCountry

ABC0001

123456

09/26/2012

77 ITEM77 Product Description - SIZE 77 6.12 471.2478 ITEM78 Product Description - SIZE 78 7.93 618.5479 ITEM79 Product Description - SIZE 79 3.80 300.2080 ITEM80 Product Description - SIZE 80 5.60 448.0081 ITEM81 Product Description - SIZE 81 7.62 617.2282 ITEM82 Product Description - SIZE 82 7.09 581.3883 ITEM83 Product Description - SIZE 83 4.96 411.6884 ITEM84 Product Description - SIZE 84 6.07 509.8885 ITEM85 Product Description - SIZE 85 2.32 197.2086 ITEM86 Product Description - SIZE 86 3.07 264.0287 ITEM87 Product Description - SIZE 87 0.61 53.0788 ITEM88 Product Description - SIZE 88 8.34 733.9289 ITEM89 Product Description - SIZE 89 3.30 293.7090 ITEM90 Product Description - SIZE 90 1.74 156.6091 ITEM91 Product Description - SIZE 91 2.18 198.3892 ITEM92 Product Description - SIZE 92 6.07 558.4493 ITEM93 Product Description - SIZE 93 8.92 829.5694 ITEM94 Product Description - SIZE 94 0.25 23.5095 ITEM95 Product Description - SIZE 95 1.58 150.1096 ITEM96 Product Description - SIZE 96 5.91 567.3697 ITEM97 Product Description - SIZE 97 3.27 317.1998 ITEM98 Product Description - SIZE 98 6.28 615.4499 ITEM99 Product Description - SIZE 99 3.75 371.25

100 ITEM100 Product Description - SIZE 100 5.22 522.00

Page No. 3