Digital Prescription Form

Please complete all of the specified fields below to submit your order for Boutique Whitening trays.

This is supplied when you purchase bleaching gel. If your voucher does not have a code, you can email an image to
Delivery Options:
Trays required: *
Platform Used: *
Please provide the links to the files here. This helps keep all the information together. However, should this not be possible, please email to as well as submitting this form.