SINUS CENTER

SINUS CENTER

Allergy Drop Refill Form
Name*

Patient first namePatient last name
Email*
example@example.com
Patient date of birth*

MonthDayYear
Date
Phone number*
Last date allergy drops taken

MonthDayYear
Date
Drops available 7 days from the next business day (i.e. if refill is placed on a Saturday, day 1 is Monday; drops will be ready for pickup or shipment the following Monday by Noon
Pickup/ship-to location (select one)*

444 N. Westhill Blvd, Appleton, WI, 54914119 E. Bell Street, Neenah, WI, 54956515 S. Washburn Street, Suite 200, Oshkosh, WI 54904Ship to the below WI residential address. I understand I will be assessed an additional $20 shipping fee. Tracking information will be emailed.
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name on Card
Select Billing Option*

Card on file 1-8 antigen allergy drops - pickup Total: $275Card on file 1-8 antigen allergy drops + shipping Total: $295 ($275 + $20)Card on file 9-15 antigen allergy drops - pickup Total: $325Card on file 9-15 antigen allergy drops + shipping Total: $345 ($325 + $20)Please call me for payment
Should be Empty: