U.S. orders only   Click here for PDF version
Please print and complete this form or use a blank page to provide the following information.
Mail your order to:
                                Gentle Pharmacy Laboratories
                                P.O. Box 29723
                                San Antonio, TX 78229-0723

ClearPatch® Lotion How
many
 Price
US$
 Total
Progesterone USP 5%, 1 fl. oz.
23.95
Progesterone USP 1.5%, 1 fl. oz.
14.95
Estriol USP 0.15% and
Progesterone USP 1.5%, 1 fl. oz.
26.95
DHEA 1.5%, 1 fl. oz.
16.95
Total first-time order discount and other discounts (**)
(see home page)


Shipping *


If shipped within Texas, add 8.125% sales tax (including shipping)


Grand Total



* Shipping charge with delivery confirmation:  Priority Mail -  up to 6 bottles - $4.95
                    First Class Mail: 1 bottle - $2.60, 2 bottles - $2.95, 3 bottles - $3.10
** Orders for $100 and over (including shipping) qualify for 10% discount, which will be applied at the time of order processing.

 Shipping Address:

 Name _____________________________

 Street _____________________________

 City __________________________ State ____  Zip ________

 Phone: (______) - ____________________ Email: _________________________

 Method of payment:

 - Check or Money Order (payable to Gentle Pharmacy Laboratories)
OR
- MasterCard, Visa, AmEx, Discover

 Card number _________________________________________

Expiration date ______________________

 Signature  ___________________________________________

 Billing Address (if different than shipping):

 Name _____________________________

Street _____________________________

 City __________________________ State ____  Zip ________


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Gentle Pharmacy Laboratories