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?
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

Allergy Drops

3 Month Supply

$280.00

Allergy Drops

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

$560.00

Shipping

Drops shipped to your address

$10.45

Total

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: