BILLING AND SHIPPING INFORMATION
Please make sure the billing information you enter is the same as the billing address for the credit card with which you plan to pay. When you have completed the following form, please click SUBMIT INFORMATION below to continue to the payment page. NOTE: Fields marked with an * are required.
NOTE: For IN-STORE pickup or Delivery to an IN-HOUSE patient use 00000 for the Zip Code to avoid shipping charges.
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Proceed to the Payment Page.
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