CHECKOUT PAGE

Complete this form and your order will be shipped within 3 days

First Name: Age: Payment Method

Last Name: Under 18

E-mail: 18-Over

Home Tel#: () - Work Tel#: () -
Enter Your Delivery Address - Including Zip Code:
"Is the address correct?"

Credit Card (complete if payment by credit card):

Visa

Mastercard Card#:

Discover Expiration Date:

Amex

Insurance (complete if covered/approved):

Insurance Company:

Policy #:

Approval #:

Blue Cross/Blue Shield Insurance (complete if covered/approved):

Policy #:

Approval #:

Total Charges = $0.00

First Name:	Age:	Payment Method
Last Name:	Under 18
E-mail:	18-Over