Order Form

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Larreastat Special Offers
6 & 3 Month Supply of Larreastat

To: Boyce N. Berkel, MD
c/o Unique Enterprises
2330 Kings Point Drive
Largo, Florida
FAX: 727-595-3181

For Fast Secure Online Ordering Click Here!

Item#	Product	Qty	Price Each	Total Cost
Best Value (6 mos)	Larreastat		$184.97
3 Month Special	Larreastat		$97.97
			S/H	FREE
			Total

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State:	Zip Code:		Country:
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Payment Type	Check	Money Order	Credit Card
Exp.	Visa	M/C	Discover	Amex
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Shipping address if different from above:




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