Online Supplement Order Form

First Name

Last Name

Street Address

City

State

Zip Code

Phone

Are you an existing patient of Dr. Meier?

Yes No

Item #1 Brand

Item Description

Size (if applicable)

Quantity

Item #2 Brand

Item Description

Size (if applicable)

Quantity

Item #3 Brand

Item Description

Size (if applicable)

Quantity

Preferred method of receiving:

I will pick up in office when the order if ready. Ship order to...

Shipping Address

Use above name and address Use ship name and address

Ship First Name

Ship Last Name

Ship Street Address

Ship City

Ship State

Ship Zip Code

Message

Items will ship on the day that payment is collected. Free standard shipping on orders of $175 or more. $10 standard shipping charge for orders under $175 for 2-3 day shipping. Additional charges may apply for expedited shipping requests.