Allergy Drop Order Form

Allergy Drop Order Form

Please allow up to 2 weeks for mixing
Name

First Name Last Name
Date of Birth

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

I will Pick them upPlease mail them to me for $9.90
Deliver to Address (Only required if different than your Billing Address below)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If you chose to pick up your drops, please indicate which location

AlleganGrand HavenGrand RapidsGrandvilleHolland

Credit Card Information (Required)*

Allergy Drops3 Month Supply

$280.00

Allergy Drops6 Month Supply (Pre-approval from your Provider is required for 6 month supply orders)

$560.00

ShippingBox must be checked to have product shipped

$9.90

Total

$0.00

Please verify that you are human*
DO NOT CLICK THE SUBMIT BUTTON MORE THAN ONCE OR DUPLICATE CHARGES WILL OCCUR TO YOUR CREDIT CARD
Should be Empty: