Product Order Form

Practice Name*

Contact Name*

First NameLast Name

E-mail*

example@example.com

Contact Number*

Area CodePhone Number

Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is billing address same as billing address?*

YesNo

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ENGLISH VERSION Please order (includes shipping to 1 location):*

SPANISH VERSION Please order (includes shipping to 1 location):*

Special Instructions

Thank you for your order! You will receive a confirmation email and acknowledgment as well as shipping information. Product ships out in 1-3 days from Central Florida. If you have any questions, please contact Jason if you have any questions 321-277-1167 or jason.mages@gomatchup.com

You will be invoiced via email and can pay via credit card or check.

Additionally, if you want to print the flyer yourself, click on the below link:

https://www.flmedical.org/florida/Florida_Public/Docs/Legis/Nonopioid-Alternatives-Law-Update-HB-743.pdf

Order Your Non-Opioid Alternatives Flyer (English & Spanish)

Flyer Specs