Allergy Drop Order Form

Allergy Drop Order Form

Please allow up to 2 weeks for mixing
Name

First Name Last Name
Date of Birth

Year Month Day
Date
Email Address
example@example.com
Will you be picking up the drops or having them mailed to you?

I will Pick them up Please mail them to me for $8.95
If you chose to pick up your drops, please indicate which location

Allegan Grand Haven Grand Rapids Grandville Holland

Credit Card Information

Allergy Drops

$ 280.00

Shipping This box must be checked if you want the product shipped

$ 8.95

Total

$ 0.00