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ORDER FORM - AUSTRALIA

Retail Order Form - Prices in Australian Dollars

This is a secure order site
Send Your SINUS RINSE™ Order By Any Of The Following Methods:
Mail Please print the form, fill out your order, then mail to:
NeilMed Pharmaceuticals Australia Pty. Ltd
12-354 Chisholm Rd
Auburn, NSW 2144
Australia
By Tel:  Please call 1300-652-148 or 1800 158-900     to place your order.
By Fax:   Please print the form, fill out your order, then fax to (1300) 652-149
By Web:   Please fill out the on-line form below , then press the SUBMIT button.(Via Secure Server)
(Physicians, Chemists, Pharmacies, Hospitals and Retailers; please call us for wholesale prices.)
Products
Price
Quantity
Total
sinusrinse kit
A$21.99
A$27.25
A$7.75
 New
A$10.99
A$21.99
 New
A$15.99
A$21.99
A$8.95
A$8.95
 New
A$20.99
A$7.30
A$9.75
 New
A$10.99

SUB TOTAL(A$)

      SHIPPING & HANDLING  

Rebate

(GST included)    TOTAL(A$)

All credit card transactions will be charged in USD.To offset the additional charge for this by your bank, we will give you a 2% discount on the net total.
Credit Card Transaction Discount (-2%)  

-

Net Billable Amount(A$)

Items With " * " Are Required
Please provide us with the following information:  

Credit Card *
 Visa             Mastercard
 Discover     Amex

Check Enclosed  ______

Credit Card #*

Select Expiration Date (MM/YYYY)

 

Month* Year*

 

Billing  Address

First Name *

  MI Last *

Address *

 

Address2

 

City *

   Province * ZIP *

Country *

Day Phone *

   Email *

If shipping address is same as above Check this Box:

Shipping Address(If not given, we will ship to your billing address)

First Name 

  MI Last 

Address 

 

Address2 

 

City 

   Province    ZIP 

Country 

 

Day Phone 

 

How did you find out about our product? *
If OTHER, explain:  

Did your physician recommend NeilMed's SINUS RINSE products to you?      Yes         No

If advised by physician, please provide their name, city and state so we can update their office about products and literature.The information that you provide will be used to send brochures and samples of our product to your physician.:(All data is kept confidential) Privacy Policy

Physician First Name

 

Physician Last Name

 

Address

 

City

   Province Country  

If available please provide your physician's:

Day Phone

  ZIP  

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