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Customer First Name________________________ Last Name_______________________________
Name As Appears On Card_____________________________________________________________
Shipping Address_____________________________________________________________________
City_________________________________ State__________ Zip___________________________
Billing Address_______________________________________________________________________
City_________________________________ State__________ Zip_____________
Phone (Including Area Code)______________________________ E-Mail______________________
Credit Card Type____________________ Credit Card #____________________________________
3-Digit Security Code_________ Exp. Date_____________
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SHIPPING AND PAYMENT INFORMATION |
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3.38-Ounce Tube $5.49 Each Suggested Re-Sale Price to Patients - $10.95 Total Units Ordered________ Total $________ |
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36-Ounce Europump - Professional Size $38.50 Each Total Units Ordered________ Total $________ |
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1-Gallon Jar - Professional Size $89.95 Each Total Units Ordered________ Total $________ |
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In-Office Countertop Display with 12 3.38-Ounce Tubes $65.88 Each Total Units Ordered________ Total $________ |
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Gravity Dispenser Display with 100 .25-Oz Trial Sachets $29.95 Each Total Units Ordered________ Total $________ |