Please print out the following information and mail it to us with your check or money order.
| Name: | Date: | ||||
| Address: | |||||
| City: | State: | Zip: | |||
| Country: | Tel: | ||||
| Email: | |||||
| Product Description | Quantity | Unit Price | Total Amount |
| Lacteeze Drops - bottle | USD$9.00/bottle | ||
| Lacteeze Drops - case | USD$90.00/case | ||
| Lacteeze Drops (15.5ml) - bottle | USD$13.00/bottle | ||
| Lacteeze Drops (15.5ml) - case | USD$138.00/case | ||
| Extra Strength Lacteeze Tablets - bottle | USD$12.00/bottle | ||
| Extra Strength Lacteeze Tablets - case | USD$126.00/case | ||
| Lacteeze Ultra (40 Tablets/bottle) | USD$16.99/bottle | ||
| Lacteeze Ultra (60 Tablets/bottle) | USD$10.79/bottle | ||
| Children's Lacteeze Tablets - bottle | USD$12.00/bottle | ||
| Children's Lacteeze Tablets - case | USD$126.00/case | ||
| Total Product Cost | $ | ||
| Shipping | $ | ||
| Total Amount | $ | ||
| Any additional instructions/information/comments or suggestions you would like to provide us: |