Order Form: Over the Counter Products

Completing this form may take some time, but we feel that the convenience, speed and cost savings to you are worth it.

Please provide the following information:

First name

Last name

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Country

Work Phone

Home Phone

FAX

E-mail Please check it carefully

CAREFULLY ENTER THE FOLLOWING INFORMATION:

Product 1: Enter the name and strength of the product in mg.

How many do you take/use per day?

For how many days would you like?


In order for us to get your products to you as soon as possible,
Please provide your credit card information:

BILLING

Credit card

Cardholder name

Card number

Expiration date

The cardholder agrees that Home Shopping Pharmacy will automatically bill the subscriber credit card.

Yes, I agree.

Yes No

Where did you hear about Home Shopping Pharmacy?

Special Instructions, if any:

Legal Disclaimer: We do not directly or indirectly dispense medical advice. We do not diagnose or prescribe medications for you. If you are prescribing over the counter medications for yourself, which is your constitutional right, we assume no responsibility.

*First name*
*Last name*
*Street address*
*Address (cont.)*
*City*
*State/Province*
*Zip/Postal code*
*Country*
*Work Phone*
*Home Phone*
*FAX*
*E-mail*	Please check it carefully

	BILLING
*Credit card*
*Cardholder name*
*Card number*
*Expiration date*

Order Form: Over the Counter Products

Copyright 1996. Home Shopping Pharmacy.