Toothpillow Checkout (Essential Plan)

1
Child/Patient Name* This field is required.Each child must be submitted separately
First Name
Last Name
2
Parent/Guardian Name* This field is required.
First Name
Last Name
3
Your 24-month PlanPay in full here. For finance options through third-party reach out to your Treatment Coordinator for guidance.
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ORDER SUMMARY
Total costUSD
Essential Plan
24 months of guide appliance therapy with an  airway-specialized doctor. A session with a Toothpillow myofunctional therapist.
$1,995.00Edit
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First Name
Last Name
4
Which color Toothbrush would they like?* This field is required.burst kids sonic toothbrush
Pink
Blue
Purple
$25 Amazon Gift Card
5
Which color Travel Case would they like?* This field is required.
Pink
Blue
Purple
Aqua
6
Which color oral appliance would they like?* This field is required.**Parents please note: If your treating provider has prescribed a Myobrace oral appliance for your child when they begin treatment, then you will receive a mouthpiece that is transparent and will have no color in appearance.**
Pink
Blue
Purple
Clear
7
Which flavor fluoride-free toothpaste would they like?* This field is required.
Orange
Fresh Mint
Vanilla Frosting
Zebra Sample 3-Pack
8
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