Please provide the following information:
| First name | ____________________________________________________ |
| Last name | ____________________________________________________ |
| Street address | ____________________________________________________ |
| Address (cont.) | ____________________________________________________ |
| City/Town | ____________________________________________________ |
| State/Province | ______________________________ |
| Postal code | ___________________ |
| Country | ______________________________ |
| Work Phone | ______________________________ |
| Home Phone | ______________________________ |
| FAX | ______________________________ |
| ______________________________ |
Please do not forget to include your payment and your doctors prescription with this order.
If paying by credit card, please fill in the details below.
| Credit card: | VISA / MASTERCARD / AMEX |
| Cardholder Name: | _________________________________________ |
| Card number: | _______ _________ ________
________ nnnn nnnn nnnn nnnn - please |
| Expiration date: | nn/nn - please |
Post to: Quins Unichem Gore
Pharmacy, 104 Main Street, Gore, New Zealand.
Phone: (03) 2087359 Fax: (03) 208 1668