Order Form
This is a secure form
Date
MM
/
DD
/
YYYY
Rep Name
Prefix
First
Last
Suffix
Account Status
New Account
Existing Account
Retail Store/
Practitioner Name
Contact Person
(Complete contact info for new accounts only)
Email Address
Phone Number
###
-
###
-
####
Shipping Address:
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Billing Address:
Same as shipping address
Different from shipping address (see below)
Billing Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Order Information
Number of units: Minimum order of 6 units required.
Cold & Sinus Solution:
Triple Allergy Defense:
Triple Flu Defense:
Introductory Offer
Yes
No
Materials:
POP counter display
Brochures
Special Instructions:
Free Shipping on orders of 12+ units, any combination of product. Standard Shipping is $8.95
Payment Information
Please call to provide credit card information.
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