Print This Form For Fax/Mail Orders

To: Boyce N. Berkel, MD
2330 Kings Point Dr.
Largo, Florida 33774
FAX: 727-595-3181


For Fast Secure Online Ordering Click Here
Item#
Product
Qty
Price Each
Total Cost
2 1/2 oz.
PainBreak
$15.97
    S/H
$4.97
 
Total
Name:
Address:
City:
State: Zip Code: Country:
Telephone Number:
Fax Number:
E-mail Address:
Payment Type
Check
Money Order
Credit Card
 
Exp.
Visa
M/C
Discover
Amex
Credit Card Number:
Shipping address if different from above:
Location of pain or shingles:

Thank You!
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