Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
How would you like to receive your shirt?
*
I will pick it up from the MedWish warehouse.
I will be paying for shipping to have it sent to my address.
T-Shirt Sales
*
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( X )
Short Sleeve T-Shirt
Sizes XS-4XL
$
35.00
Size
Quantity
XS
1
2
3
4
5
6
7
8
9
10
S
1
2
3
4
5
6
7
8
9
10
M
1
2
3
4
5
6
7
8
9
10
L
1
2
3
4
5
6
7
8
9
10
XL
1
2
3
4
5
6
7
8
9
10
XXL
1
2
3
4
5
6
7
8
9
10
3XL
1
2
3
4
5
6
7
8
9
10
4XL
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Long Sleeve Hooded T-Shirt
Sizes XS-2XL
$
43.00
Size
Quantity
XS
1
2
3
4
5
6
7
8
9
10
S
1
2
3
4
5
6
7
8
9
10
M
1
2
3
4
5
6
7
8
9
10
L
1
2
3
4
5
6
7
8
9
10
XL
1
2
3
4
5
6
7
8
9
10
XXL
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Shipping
Would you like your shirt shipped? If selected, it will be shipped to the address indicated above.
$
7.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Submit
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