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:
    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.