Product Order Form

 

PRODUCT ORDER FORM
Date:      
Name:      
Shipping Address:      
City, State, Zip      
Phone Number(s):      
Email:      
     
Please CIRCLE Mail-Out Order or Pick-Up: MAIL-OUT ORDER PICK-UP ORDER
FOR PICK-UP ORDERS:      
If Pick-Up Order, list date/time you will P/U:      
Please note, that for pick-up orders, 4 hours advance notice is required. All products will be re-stocked after
one(1) week, so if you cannot come and get your order within one (1) week of us calling you, you MUST
phone us or your order will be re-stocked.      
FOR MAIL-OUT ORDERS (all orders must be paid for in advance):    
Do we have your credit card on file and is this the credit card you want us to use?    
If yes, please indicate the last four digits of your credit card number so we may confirm:  
If we do not have your credit card number on file, you must phone us with the number or you may fax  
this completed form to 210-340-2430. PLEASE DO NOT EMAIL CREDIT CARD NUMBERS.  
Do you want us to mail ALL your products together or can we send a PARTIAL order? (please circle answer)
Products Needed:
Vendor Name Product Name Product Size Quantity Needed
(ex. Dayspring, Standard Process, etc.) (ex., Bugleweed, AF-Betafood) (ex., 1 oz., 4 oz., 360T)
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
Do any of your products say "MIX" on the label? If so, please indicate above next to product item.
PLEASE NOTE THAT EFFECTIVE IMMEDIATELY, ALL BIO-MED ORDERS MUST BE PRE-PAID.
NOTE: THIS FORM MUST BE COMPLETELY FILLED OUT; ANY MISSING INFORMATION
WILL RESULT IN YOUR ORDER NOT BEING PROCESSED.
SIGNATURE: