B12 Payment

Integrity Family Practice

B12 Cyanocobalamin 30ml
I authorize Integrity Family Practice to charge my credit card in the amount of $120. This includes the Medical Evaluation, Prescription, and delivery of B12 Cyanocobalamin 30ml. I fully understand that if for any reason this prescription can not be fulfilled I will be returned the full amount of payment.

I likewise certify that I am the authorized user of the Credit Card that shall be submitted through this form. As long as the transactions correspond to the terms and conditions indicated in this authorization, I shall not raise disputes against Integrity Medical Weight Loss. Once a prescription is ordered there are no refunds. No exceptions.
Name

First NameLast Name
Is your Billing and Shipping address different?
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shiping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
By submitting this form, you shall be redirected to PayPal to complete the authorization Process for charging from your account
Signature
Date

MonthDayYear
Date
My Products
prevnext( X )
B12 Cyanocobalamin 30ml$0.01
This includes the Medical Evaluation, Prescription, delivery of 30ml B12 Cyanocobalamin (30 week supply), and 30 1ml subcutaneous syringes.

Quantity

Total $0.00
Should be Empty:

Integrity Family Practice