DISPENSARY ORDER FORM 20121 by xQMDpm0

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									                                 DISPENSARY ORDER FORM


DATE:

SHIP TO
NAME:
ADDRESS:
CITY:             STATE:                              ZIP:
BEST CONTACT NUMBER:

CHARGE TO
LAST 4 of CREDIT CARD:
EXPIRATION DATE:
CVC (3-digit code on back of card right side):

SHIPPING METHOD (check one):

UPS GROUND     UPS 3-DAY     UPS 2-DAY    UPS OVERNIGHT
UPS OVERNIGHT SAVER      SIGNATURE RELEASE

USPS (will ship next MCNH business day)

Custom Herbal Blends
                      QTY            SIZE         NAME OF BLEND & PROTOCOL DATE
Herbal Tonic
Tea or Extract
Lotions, Salves, etc.
Supplement Order
    QTY         PRODUCT BRAND                    PRODUCT NAME     DESCRIPTION/SIZE
QTY   PRODUCT BRAND   PRODUCT NAME   DESCRIPTION/SIZE

								
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