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3-Ounce Patient Roll-On - Case of 12 12 Per Case - $81.00 - Unit Cost $6.75 - Suggested Retail Price to Patients $15.00-$20.00 Order ________ Cases Total $________ |
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Individual Bottles 4-Ounce Patient Spray OR 4-Ounce Patient Gel OR 3-Ounce Patient Roll-On Single Bottle - Unit Cost $10.00 - Suggested Retail Price to Patients $15.00-$20.00 Order ________ Units Total $________ |
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16-Ounce Clinic Spray Bottle Unit Cost $26.00 - Suggested Retail Price to Patients $54.00-$68.00 Order ________ Units Total $________ |
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4-Ounce Patient Gel - Case of 12 12 Per Case - $81.00 - Unit Cost $6.75 - Suggested Retail Price to Patients $15.00-$20.00 Order ________ Cases Total $________ |
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16-Ounce Clinic-Size Gel Pump Bottle Unit Cost $26.00 - Suggested Retail Price to Patients $54.00-$68.00 Order ________ Units Total $________ |
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4-Ounce Patient Spray - Case of 12 12 Per Case - $81.00 - Unit Cost $6.75 - Suggested Retail Price to Patients $15.00-$20.00 Order ________ Cases Total $________ |
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1/4 Gallon Clinic-Size Spray Unit Cost $51.00 - Suggested Retail Price to Patients $102.00-$129.00 Order ________ Units Total $________ |
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Individual Application Gel Pack - Pack of 5 Unit Cost $2.00 - Unit Cost 40˘ - Suggested Retail Price to Patients $5.00 Order ________ Units Total $________ |
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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 |