Allergy Drop Order Form

Allergy Drop Order Form
PLEASE ALLOW UP TO 14 BUSINESS DAYS FOR MIXING
Patient Name *

First NameLast Name
* The person that the drops are being ordered for, not the parent or guardian's name that's filling out the form for the patient.
Patient Date of Birth

YearMonthDay
Date
Email Address
example@example.com
Will you be picking up the drops or having them mailed to you?

I will Pick them upPlease mail them to me for $10.45 (only available for Michigan mailing addresses)
Deliver to Address (Only required if different than your Billing Address below)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you chose to pick up your drops, please indicate which location

AlleganGrand HavenGrand RapidsGrandvilleHollandCaledonia

Credit Card Information (Required)*

Allergy Drops3 Month Supply

$280.00

Allergy Drops6 Month Supply (Pre-approval from your Provider is required for 6 month supply orders)

$560.00

ShippingDrops shipped to your address

$10.45

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Comments:
Please verify that you are human*
DO NOT CLICK THE SUBMIT BUTTON MORE THAN ONCE OR DUPLICATE CHARGES WILL OCCUR TO YOUR CREDIT CARD
Should be Empty: