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Unique
Enterprises
Fax Order Form |
Boyce
N. Berkel, MD
2330 Kings Point Dr.
Largo, Florida 33774
FAX:888-268-2795
Email: painrlfctr@aol.com
24
Hour Automated Order Line!
1-888-268-2795 |
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| Name: |
| Address: |
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| City |
State: |
Zip: |
| Visa |
Mastercard |
Discover |
Amex |
(circle one) |
Check/Money Order |
Credit Card #: |
Expiration Date |
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| Comments: |
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| Item |
Product |
Quantity |
S/H |
Price Each |
Total Cost |
| Tube (2.5 oz) |
PainBreak |
|
$4.97 |
$15.97 |
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| 3 for 2 |
PainBreak Special |
|
$5.97 |
$31.97 |
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| 6 tubes |
Excellent Value |
|
$8.97 |
$77.82 |
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| 12 Tubes |
Best Value |
|
$12.97 |
$119.64 |
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| Capsules |
LarreaRX |
|
$4.97 |
$32.97 |
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| Book |
Living With Shingles |
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$8.97  |
$19.97 |
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Sub |
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| Shipping and Handling
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Date:
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Total |
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