PHYSICIAN ORDER PATIENT SPECIFIC ORDERPlease use this form for only one patient. You can submit this form multiple times for different patients.PATIENT NAME*(Patient )Date of Birth*(Patient) Phone*Allergies*(Patient) Email ORDERING PHYSICIANS NAME*ASCORBIC ACID 500MG/ML. 30ML VIAL PRESERVATIVE FREE (REFRIGERATED) Quantity Price: $129.00 Quantity Inject 1ml intramuscularly twice per week as needed.B12 (Cyanocobalamin) 2000mcg 30ML Vial Quantity Price: $99.00 Quantity B12 (Methylcobalamin) 10,000mcg Powder (Constitute with Bacteriostatic Water) Quantity Price: $89.00 Quantity Bacteriostatic Water 30ml vial Quantity Price: $10.00 Quantity B-Complex (B1 / B2 / B3 / B5 / B6) (Refrigerated) Quantity Price: $149.00 Quantity Dexapanthanol (B5) 250mg/ml 30ml Vial Quantity Price: $120.00 Quantity Pyridoxine HCl (B6) 100 mg/ml 30ml Vial Quantity Price: $120.00 Quantity Folic Acid 5mg/ml 10ml vial Quantity Price: $149.00 Quantity L-Arginine 200mg/ml 30ml vial Quantity Price: $149.00 Quantity L-Carnitine 500mg/ml 30ml vial Quantity Price: $149.00 Quantity Glutathione 200mg/ml 30ml vial (preservative free) Quantity Price: $149.00 Quantity MIC (LIPOTROPIC) 25/50/50 MG/ML 30ML VIAL Quantity Price: $130.00 Quantity Total $0.00 +Plus Shipping ($20 for Standard Shipping) OR ($60 for Overnight, all cold products require overnight Shipping) FOR MULTIPLE CLINIC ORDERS PLACED ON THE SAME DAY, THERE WILL ONLY BE 1 COMBINED SHIPPING COST.BILL:* PHYSICIANS OFFICE PATIENT Credit Card Number*Expiration Date (xx/xx)*CVC*Billing Zip Code*SHIP TO:* PHYSICIANS OFFICE PATIENT SHIPPING ADDRESS (FOR ORDER) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Minimum order quantity for Clinic orders is $3000, please do not submit orders below this quantity as they will not be processed. You can place multiple orders for different patients. Total of all orders,for the day, should meet the minimum.* My order/orders meet the minimum This is a non-refundable order.* I AGREE PHYSICIAN SIGNATURE*Date* MM slash DD slash YYYY Δ
