YOUR ACCOUNT IS OPEN - PLEASE SEND THE FOLLOWING: PRODUCT CODE NAME QUANTITY UNIT PRICE TOTAL 32010 OPTHAL GEL 10 g $7.90 S&H SHIPPING AND HANDLING 1 $15.00 TOTAL Minimum order quantity is 12 units KINDLY FILL IN ALL INFORMATION REQUESTED NAME OF DOCTOR/CLINIC: ADDRESS: CITY: PROVINCE: AB BC MB NB NL NS NT NU ON PE QC SK YT POSTAL CODE: TEL: FAX: EMAIL: BUYER'S NAME: *Tear Gel is a trademark of Alcon Pharma Inc. Opthal Gel is a trademark of Stom Pharma Inc. Δ