TO PLACE AN ORDER PLEASE FILL IN THE THE INFORMATION BELOW AND PRESS THE

SUBMIT BUTTON.

WE WILL PROCESS THE ORDER THE DAY WE RECIEVE IT.

YOU CAN ALSO PRINT OUT THIS PAGE AND FAX THE ORDER TO US AT:

fax.gif (481 bytes) 1-718-980-6803

OR

CALL US TOLL FREE AT

                               1-888-249-6625-888-249-6625

TO PLACE AN ORDER BY phone1.gif (221 bytes)

a-line1.gif (7186 bytes)

WE ACCEPT:

amex.gif (7440 bytes)    visa-MASTER-ANI.gif (24886 bytes)    visa.gif (4083 bytes)     writeacheck.jpg (3612 bytes)

(SEE BELOW FOR INFORMATION ON HOW TO PAY BY CHECK/MONEY ORDER)

 

ORDER FORM

 

 

 

NAME
ADDRESS
CITYSTATEZIP CODE
COUNTRY
PHONE
E-MAIL


BILLING INFO:

CARDHOLDER NAME
CARD #EXP DATE
CREDIT CARD

ORDER

ITEMQTYPRICE
ITEMQTYPRICE
ITEMQTYPRICE
ITEMQTYPRICE
                                   SUBTOTAL
                                   SHIPPING
                                         TOTAL
                                                  

 

SHIPPING & HANDLING CHART

(FOR SHIPPING WITH THE CONTINENTAL U.S ONLY! OUTSIDE THE U.S. PLEASE CALL OR E-MAIL TO OBTAIN SHIPPING COST)

$0 - $30.00 $ 3.00
$ 30.01 - $50.00 $ 5.00
$ 50.01 - $ 100.00 $ 7.50
$ 100.00 - $ 200.00 $ 10.00
$ 200.01 - ? CALL FOR PRICE QUOTE

 

TO PAY BY CHECK OR MONEY ORDER:
PLEASE PRINT THIS FORM AND MAIL PAYMENT TO:

MIDLAND PHARMACY
6060 MIDLAND AVE
STATEN ISLAND, NY 10306
USA