Psi-clone and Suck-cess Order Form

THIS IS FOR WASHINGTON STATE DENTISTS ONLY

Randy's Compounding Pharmacy & Nutrition Center
1908 E. 4th Ave.
Olympia, WA   98506
1-800-455-6888
(360) 491-0607
FAX:     360-491-0629
e-mail:  info@soundcompounding.com
Website: randyscompoundingpharmacy.com

To order Psi-clone, please indicate the type and the number of 30 ml bottles  you would like and submit your
check, or credit card number along withthis order form. The prices include shipping costs.
PLEASE SUBMIT PRESCRIPTION FORM FOR SUCK-CESS-- go to Handouts, Number 11B.



        Doctor: _________________________________  Date:  ________________

          Address: _______________________________________________________

                        _______________________________________________________

          Phone: ________________________   FAX: __________________________

         Qty.                                          Doctor's Price      Subtotal

          (    )    Psi-clone 1% Liquid             $49.75             ________

          (    )    Psi-clone gel                          $49.75             ________

          (    )    Suck-cess tube                      $20.00             ________

                                                                    Total               ________
         SIG: For office use only

           Not to be dispensed or resold

          _______________________________________________________
Doctor's Signature

Method of payment:

Check enclosed (    )           Credit Card:    VISA (    )   Mastercard (    )   Discovercard (    )

Number of card: _____________________________________  Exp. date ________

Signature:   ___________________________________________________________
 


Go back to Office Handouts Page