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CHRYSALIS NATURAL MEDICINE CLINIC ORDERS

Step 1. Please enter your name, email and phone number (including area code):

First name:		Last name:
Email:
Phone number:

Step 2. Please enter your address:
My address is on file (check here if your address and credit card are already on file, and skip to step 3)
Please change my old address to the new one on this form (check here if your address has changed in the last year unless you are absolutely sure we have the new address in our records)

Address:

City, State: , Zip:

Country:

Step 3. Complete an order line for each medicine or refill you need:

Name of medicine	Amount per bottle	# of bottles
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,

Five more order lines (show/hide)...

Name of medicine	Amount per bottle	# of bottles
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,
	If pills, or, if powder,

Step 4. Delivery method (choose one):
Mail out by UPS
I will pick up inside the clinic during open office hours on

I will pick up after hours - put in milkbox
Other (put instruction in box below)

Step 5. Additional instructions, if necessary:

Step 6.

Refunds Policy
Any unopened medicine, except individualized powder or tincture mixtures, can be returned within 3 months of purchase for full credit, no questions asked. (Pharmacy laws do not allow us to resell a bottle once opened.) Any bottle that shows signs of tampering or contamination when you first open it at home -- funny smells or odd coloration etc. -- will also be refunded.